Intake Forms

Aron Hirschfeld, LMSW

Intake forms
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email
example@example.com
By providing my email address, I hereby give Aron Hirschfeld permission to communicate with me via email, including but not limited to sending receipts for therapy services.
May I ask how you heard of me and may I thank him/her for referring you to my office?
Have you received any counseling before?

Yes No
When and where did you receive service(s)?
How many different therapists have you seen?
Therapists’s Names (optional):
What did you find most helpful in therapy?
What did you find least helpful in therapy?
As you see it, what is bothering you most right now?
Has anything happened like this before?

Yes No
When?
What led you to seek help at this time?
How would you like to change things?
What do you do to help you feel better?
What was the happiest time of your life?
What was the worst time of your life?
Ideally, what would you like to get from therapy?
Please add any additional information which you feel may be important for me to know.
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Date

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Date

Practice Policies
Appointments

You must make an appointment to be seen. Most sessions run between 45-55 minutes.

Emergencies

In the event of an emergency, the best practice is to go to your local hospital emergency room where you can get immediate attention and medical assistance. You should also call your clinician and indicate that there is an emergency. Your clinician will get back to you as soon as possible but cannot guarantee an immediate response. Please be advised that notifications for calls, text messages, and emails are turned off between the hours of 9:00pm and 8:00am or on the weekends. Your message will be returned during normal business hours.

Cancellations

Your session time is reserved for you. Please contact your clinician at least 24 hours in advance if you need to change or cancel a scheduled appointment. Except in instances of illness or emergency, appointments that are not canceled in a timely manner will be billed directly to you in their entirety (not just the co-pay) as your insurance company will not cover them.

Fees

The fee for an initial one-hour interview and assessment is $180. Additional sessions thereafter are forty-five minutes at a rate of $150, unless otherwise arranged via your insurance company or directly with your clinician. If you are using your insurance, you are responsible for payments or insurance co-pay at the time of each appointment.

Confidentiality

The Health Insurance Portability and Accountability Act of 1996 requires that our private health information is kept confidential at all times. Without your written permission, we cannot release any information about you. We will request permission in the event that someone else needs such information. You can revoke this authorization at any time.

You should also note that there are certain exceptions to the privacy rules. By law, we are required to report the following situations: (1) suspected abuse of a child or vulnerable adults; (2) suicidal and/or homicidal threats; (3) certain law enforcement situations; (4) emergencies that involve legal investigations. Please note that according to state statutes governing psychologists, adolescents over the age of 14 have a right to privacy with respect to sexual activity, pregnancy issues, and substance use. In the event these are issues in the treatment of a given adolescent, we will make every effort to encourage a teen to share information with family members, especially if such sharing is not felt to be harmful to the child.

Use of Social Media

We do not accept any friend requests on any social media platform (Facebook, Twitter, LinkedIn, etc.) from any current or future client. We believe that adding clients as friends on these sites would compromise clients’ confidentiality as well as impact our respective privacy. We also believe that contact on social media blurs the lines and impacts the therapeutic relationship negatively.

Use of Email & Text Message

Please note that email and text messages are not considered HIPAA compliant forms of communication. You may contact us through these platforms; however, please be aware that if you choose to do so, you may compromise your confidentiality. If you communicate confidential or private information via text or email, we will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted. Please do not use e-mail or texts for emergencies. Due to computer or network problems, emails may not be deliverable, and we may not check our emails daily.
*

I have read and understand the above
Client Signature *

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Date *

Month Day Year
Date

Informed Consent For Treatment
My choice to engage in treatment is voluntary and I understand that I may terminate therapy at any time.

I understand that there is no assurance that I will feel better. Because psychotherapy is a
cooperative effort between me and my therapist, I will work with my therapist in a cooperative manner to resolve my difficulties.

I understand that during the course of my treatment, I may discuss material that is upsetting and that this might be a necessary part of the process.

I understand that records and information collected about me will be held or released in
accordance with state and federal laws regarding confidentiality.

I understand that state law may require the reporting of all cases of abuse or neglect of minors and/or vulnerable adults.

I understand that state laws require reporting of all cases in which there exists a danger to self and others.

I understand that WeClique may disclose records pertaining to my treatment to approved representatives of my insurance company and my primary care physician if such disclosure is required for claims processing, case management, authorization of sessions, coordination of treatment, quality assurance or utilization review purposes. I know I can revoke my consent at any time except to the extent that treatment has already been rendered or that action has been taken.

I understand the cancelation policy and my financial responsibility for appointments canceled with less than 24 hours’ notice.
Type a question *

I have read and understand the above
Signature *

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Date *

Month Day Year
Date

List Of Clients Rights

Distributed in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
You have the right to be treated with respect.

You have the right to fair treatment, regardless of race, religion, gender, ethnicity, age, disability, or source of payment.

You have the right to have treatment and other member information kept private and released only with your written permission.

You may revoke written consent to release information at any time.

Records can only be released without permission in the event of an emergency or if required by law- Examples include: public health activities, civil or criminal proceedings, law enforcement, medical examiners, research (if the proper requests have been completed) or reports of suspected maltreatment or domestic violence as required by law.

You have the right to information provided in a language you can understand.

You have the right to an easily understood explanation regarding your diagnosis and treatment.

You have a right to know about various treatment choices.

You have a right to participate in treatment plan and to know about what information is being shared with your insurance company.

You have a right to see your medical records.

All information about you that is transmitted either electronically, on paper, by fax or by phone is safeguarded by limiting access to data.
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I have received a copy of this notice
Signature *

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Date *

Month Day Year
Date
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Aron Hirschfeld, LMSW

Practice Policies

Informed Consent For Treatment

List Of Clients Rights