Heart & Soul New Client Intake Form

Heart & Soul New Client Intake Form

All new clients must fill out and submit this form before scheduling an appointment. NOTE: All information collected is private and protected by NYS doctor-patient confidentiality laws.
PLEASE NOTE: FILLING OUT THIS FORM DOES NOT GUARANTEE AN APPOINTMENT WILL BE SCHEDULED. APPOINTMENTS ARE BASED ON AVAILABILITY AND INSURANCE COVERAGE.
PLEASE NOTE: All FIELDS WITH A RED ASTERISK * ARE MANDATORY.
Today’s Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Information
Your Current Legal Name

Prefix (optional)First Name *Middle Name (optional)Last Name *
Your Preferred Name (optional)

Prefix (optional)First Name *Middle Name (optiona)Last Name *
Your Gender at Birth
Your Current Gender Identity (optional)
If you prefer to not answer, you may leave this field blank.
Your Date Of Birth
Use your keyboard to enter your date of birth
Your Current Age
Under 18 will be required to enter parent/guardian info.
Minors (Under 18) Must Enter A Parent Or Guardian’s Name

First NameLast Name
Guardian’s Relationship To Applicant
Your Cell Phone Number
Format: (000) 000-0000.
May We Send You Text Messages?
NOTE: By opting in to text messages, you agree to receive text communications regarding appointment confirmations, tele-health session information, prescription-related communications, and other client-provider communications.
Your Email Address (optional)

Confirmation EmailPlease confirm your email address. Both emails must be the same. If you do not have an email address or prefer not to provide one, you may leave these fields blank.
Your Current Legal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

In the event of an emergency, please list the person you wish us to contact.
Emergency Contact’s Name

First NameLast Name
Emergency Contact’s Phone Number
Format: (000) 000-0000.
Contact’s Relationship To You
Example: spouse, sibling, parent, friend, etc.
Reason For Making This Appointment
I Am Seeking (you may select both)
Best Day(s) / Time(s) To Schedule Your Appointment
Your Presenting Problem
Do You Ever Feel That You've Been Traumatized?
Have You Ever Been Arrested?
If You Were Arrested Please Explain (voluntary)
NOTE: All information collected is private, and protected by NYS doctor-patient confidentiality laws. You may elect to skip this answer, but in the interest providing you with the best possible treatment, we encourage you to be forthcoming and sincere in your response.
Medical History
Are You Currently Taking Any Medications?

Your Prescriber

First NameLast Name
Have You Had Any Recent Hospitalizations?
Do You Smoke Marijuana?
How Often/How much?
Do You Drink Alcohol?
How Often/How much?
Current Health Information
{yourCurrent1},
Have you or anyone in your household had any of the following symptoms in the last 21 days; sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
Have you or anyone in your household traveled in the U.S. in the past 21 days?
Have you or anyone in your household traveled on a cruise ship in the last 21 days?
Are you or anyone in your household a health care provider or emergency responder?
Medical Insurance Information

NOTE: If you are insured, your insurance information will be required, including your member ID and your provider’s phone number. This info can typically be found on your insurance card.
Are You Currently Insured?
Your Insurance Provider
If you do not see your insurance provider listed, please select the last option (Other / Not Listed) and enter your Member ID and insurance provider’s phone number if available.
Your Member ID
Can Be Found On Your Insurance Card
Insurance Provider’s Phone Number (For Providers of Mental/Behavioral Health)
Can Typically Be Found On The Back Of Your Insurance CardFormat: (000) 000-0000.
If You Do Not Have Insurance, We Must Send You A Non-Insured Client ID Code. This Code Must Be Presented At Your First Appointment To Confirm Your Identity, Or Treatment Cannot Be Provided.

If you do not have access to email or a mobile phone, please call our office at (631) 321-7011.
How Would You Like To Receive Your Non-Insured Client ID Code?
Please Enter The Email Where You Would Like Us To Send Your Code

Confirmation EmailPlease confirm your email address.
Please Enter The Mobile Phone Number Where You Would Like Us To Send Your Code
Please enter a valid mobile phone number.Format: (000) 000-0000.
Heart & Soul Center’s Policies

Please read each section carefully and follow the instructions to sign your consent.
Heart & Soul Center’s Consent To Treatment Policy
Please read this section carefully and sign in the space provided

I consent to any psychotherapy, medication assessment and management, laboratory or other medical procedures or examinations rendered me under the general and specific instructions of Heart & Soul Community Counseling, Inc., Heart & Soul Counseling, LCSW, PC. I further consent that if my provider has a supervisor, I agree to see my provider under that supervision.
I, {yourCurrent1}, hereby acknowledge that I have read and agree to Heart & Soul Center’s Consent To Treatment Policy as of {todaysDate}

Please sign with mouse or finger on phones.
Heart & Soul Center’s Cancellation Policy
Please read this section carefully and sign in the space provided

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours cancellation notice is required for rescheduling or cancelling an appointment. MISSED APPOINTMENTS ARE NOT COVERED BY YOUR INSURANCE. THEREFORE, THE CHARGES ASSOCIATED WITH THEM ARE YOUR RESPONSIBILITY

If 24-hours cancellation notice has not been given, there will be a $90 charge. This fee must be paid prior to making another appointment. This policy is necessary in order to make the time available to other clients.
I, {yourCurrent1}, hereby acknowledge that I have read and agree to the Heart & Soul Center’s Cancellation Policy as of {todaysDate}

Please sign with mouse or finger on phones.
Heart & Soul Center’s Privacy Policy
Please read this section carefully and sign in the space provided

Recognizing that certain services provided are of confidential nature, Heart & Soul Counseling LCSW, PC, Heart & Soul Community Counseling Inc. has formally adopted a policy to protect your privacy. This policy states that the information you provide will be kept confidential and will not be distributed or shared with other persons or organizations without your written approval. However, there are situations where Heart & Soul Community Counseling, Inc. has a responsibility to release information, regardless of whether the client agrees. These exceptions include:
1. Cases of suspected child abuse or neglect are required to be reported in the State of New York to the Department of Children and Families;
2. Cases of suspected abuse or neglect of the elderly and mentally challenged adults are required to be reported in the State of New York;
3. The courts have a right to order Heart & Soul Counseling LCSW, PC, Heart & Soul Community Counseling Inc., to release client information;
4. Heart & Soul Counseling LCSW, PC, Heart & Soul Community Counseling Inc., is required to make a reasonable effort to inform the police at any reason directly threatened by a client, of the client’s direct threat to harm that other person;
It is Heart & Soul Counseling LCSW, PC, Heart & Soul Community Counseling Inc., policy to keep your information confidential and to protect your privacy. However, the enactment of the HIPAA privacy rule, section 164.505 (b) requires that a client’s right to have his or her health information kept private and secure has become more than just an ethical obligation of health care professionals; it is also the law. As a result, we have established this formal in-house privacy policy. As always, we strive to provide you with the best services, along with keeping your personal information confidential.
I, {yourCurrent1}, hereby acknowledge that I have read and agree to the Heart & Soul Center’s Privacy Policy as of {todaysDate}

Please sign with mouse or finger on phones.
Heart & Soul Center’s Medication Management / Refill Requests / Changes in Medication
Please read this section carefully and sign in the space provided

When treatment involves medications, you will be provided with enough prescription refills to last you until your next scheduled appointment. If you need to cancel that appointment, you will need to reschedule before your medication runs out. Medication changes will not be made over the phone as a proper face-to-face evaluation will be necessary to determine a change in the course of care. If you have any questions about your care, please write them down to be sure they get addressed at your next meeting. If an emergency occurs between visits, please call 911 or go the nearest emergency room for an evaluation. Patient expectations for safe and effective medication management require that the client:
1. Inform Heart & Soul Counseling LCSW, PC, Heart & Soul Community Counseling Inc., when any new medical problems or medication is prescribed by other health care professionals, and of any over-the-counter medications or supplements that you are using;
2. Inform us of any side effects or suspected side effects of medication at every visit;
3. Agree not to make changes in medication dosing, including stopping medications without consulting with me, for medications prescribed by me. NOTE: IT MAY BE DANGEROUS TO ABRUPTLY STOP MEDICATIONS OR CHANGE DOSING WITHOUT CONSULTATION WITH A MEDICAL PROFESSIONAL.
4. Attend all scheduled appointments as agreed upon in order to provide proper continuity of care and to properly assess efficacy of treatment.
5. Complete all requested laboratory testing in a timely manner. Some medications cannot be safely prescribed without periodic blood work.
I, {yourCurrent1}, hereby acknowledge that I have read and agree to the Heart & Soul Center’s Medication Management / Refill Request / Changes In Medication Policy as of {todaysDate}

Please sign with mouse or finger on phones.
Thank You For Completing The New Client Intake Form

If you are satisfied with your answers, please click the "Submit Form" button. If you wish to start over, select "Clear Form" below and click/tap the "Up Arrow" icon to return to the top.
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Heart & Soul New Client Intake Form

Contact Information

Emergency Contact

Reason For Making This Appointment

Medical History

Current Health Information

Medical Insurance Information

If You Do Not Have Insurance, We Must Send You A Non-Insured Client ID Code. This Code Must Be Presented At Your First Appointment To Confirm Your Identity, Or Treatment Cannot Be Provided.

Heart & Soul Center’s Policies

Thank You For Completing The New Client Intake Form