Intake Assessment—Santa Fe Psychology

NEW CLIENT INTAKE
Clinician Providing Assessment:
- Your psychotherapist is Kila Hillman MA, LPCC. She provides in person sessions from her personal office space or teletherapy via Zoom.
  
  The confidential information gathered in this form is to help Kila gain essential information about you, provide you with information about her practice, as well as, sign the necessary forms. Some common answers are pre-selected, for the purposes of expedience, which you may change if they do not apply to you.
- Date:
  
  MonthDayYear
  Date
- Time:
  
  :HourMinutesAM/PM Option
- Photo for your Medical File:
- Name:*
  
  First NameMiddle NameLast Name
- Preferred Name:
- Birthdate:*
  
  MonthDayYear
  Date
- Age:
- Biological Sex:*
  
  MaleFemaleOther
- Gender Identity:
  
  Transgender MaleTransgender FemaleNonbinaryAgenderOther
- Ethnicity:
  
  UnknownMixed RaceWhite/CaucasianHispanic/LatinoNative AmericanBlack/African AmericanAsian Pacific IslanderOther
- Physical Address:*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Mailing Address (if different from physical address):
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Phone:*
  
  Area CodePhone Number
- Cell Phone:
  
  Area CodePhone Number
- Work Phone:
  
  Area CodePhone Number
- Email:
  example@example.com
- Emergency Contact:*
  
  Area CodePhone Number
- Name:*
  
  First NameLast Name
- Relationship to Client:
- COMMUNICATION/SCHEDULING OPT IN'S (non-Hippa Compliant (encrypted but still with interception risk)):
- TEXT
- EMAIL
- HOME PHONE VOICEMAILS
- CELL PHONE VOICEMAILS
- OFFICE PHONE VOICEMAILS
- CLIENT SIGNATURE (child's if 14 or older)*
  
  Clear
  I agree to the communication opt in's I have selected.
- Name:*
  
  First NameLast Name
- Date:
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I agree to the communication preferences I have selected.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Photo of Driver's License or Identification Card
- Driver's Licence or Identification Card*
- Insurance Card Photo
- Payment Responsibility:*
  
  primary insurancesecondary insuranceself-payorout of network benefitsOther
- Name on Card (primary insurance subscriber or self-payor):*
  
  First NameMiddle NameLast Name
- Date of Birth (primary subscriber or self-payor):*
  
  MonthDayYear
  Date
- Payment Method (insurance carrier or self-payor CC type) :*
- Payment Number (primary member ID or self-payor CC/EXP/CVV):*
- Name on Card (dependent subscriber):
  
  First NameMiddle NameLast Name
- Date of Birth (dependent subscriber):
  
  MonthDayYear
  Date
- Dependent Member ID Number:
- Dependent Subscriber Relationship to Primary Subscriber:
  
  selfdependent spousedependent childOther
- Secondary Insurance Carrier:
- Secondary Insurance Member ID Number:
- Insurance Co-payment Method (CC type):
- Insurance Co-payment Number (CC/EXP/CVV code):
- Current Psychiatrist or Prescribing Psychologist:
  
  First NameLast Name
- Current Psychiatric Medications:
- Current Counselor, Psychotherapist, Psychologist:
  
  First NameLast Name
- Past Counseling or Psychotherapy:
  
  noyesOther
- Current Symptoms:*
  
  abandonment IssuesACOA (Adult Child of Alcoholic)addictive behavioraggressive physical behavioraggressive verbal behavioralcohol use/abuseamnesiaanger issuesanhedonia (inability to feel pleasure)anorexiaanxietyapathyauditory hallucinationsbinge eatingbulimiachronic paincompulsionscompulsive gamblingcompulsive sexual behaviorcutting/other self mutilationdecreased appetitedelusionsdepersonalization (outside observation of self)depressed moodderealization (surroundings appear unreal)diet pill use/abusedifficulty w/sleep maintenancedifficulty w/sleep onsetdifficulty w/understandingdissociation (disconnected w/surroundings)distorted body imagedistortion or loss of subjective timedistractibilitydysregulation of menstral cycleemployment problemsencopresis(resisting bowel movements/leakage)enuresis (bedwetting)exaggerated startle responseexcessive exerciseexcessive internet useexcessive sleepexposure to traumatic eventfamily of origin concernsfatigue tirednessfearfear of open spacesfeelings of guilt shamefeelings of helplessnessfeelings of lonelinessfeelings of worthlessnessfinancial problemsforgetfulnessgender identity issuesgrief/loss issueshistrionic (melodramatic)homicidal thoughtshyperactivityhypervigilencehypomaniaillegal drug use/abuseimpulsive spendingincreased appetiteindecisivenessinflated self esteem/grandiosityinsomniaintense fear of weight gainintentional food restrictionintrusive thoughtsirritabilitylaxative abuselegal problemslow energylow motivationlow self esteemmalingeringmaniamarital/intimate relationship issuesmedical issuesmedical problemsmood swingsobsessive thoughtsoccupational problemsover counter drug use/abuseoverwhelmedpanic attacksparanoiaparent/child problemspeer relationship problemsperfectionismphobiapoor self imagepostpartum depressionprescription drug abuseprovocative/seductive behaviorpsychomotor agitationpsychomotor retardationracing thoughtsrecent significant weight gainrecent significant weight lossrecurrent distressing dreamsrecurrent thoughts of deathrefusal to maintain normal body weightrestlessnessSAD (seasonal affective disorder)sad moodschool problemsself induced vomitingself-neglect/poor hygienesense of entitlementsexual problemssibling conflictsocial isolationstresssuicidal thoughtstearfulnessthought blocking (thought/speech cessation)time managementvisual hallucinationsworryOther
- Areas of Life Affected:*
  
  problems with primary support groupproblems related to the social environmentoccupational problemseconomic problemseducational problemsproblems related to interaction with the legal systemproblems with access to health care serviceshousing problemsguardianship/competency problemsOther
- Severity:
  
  moderatesevereOther
- Areas Personal Functioning Affected:*
  
  marriage/intimate relationshipsfamily interactions/involvementsocial interactions/involvementschoolself careworkinvolvement in daily livingrecreational/leisure/fitness activitieshouseholdphysical healthOther
- Severity:
  
  moderatesevereOther
- Current Relationship with Alcohol:
  
  do not usemoderate usemild useheavy useexcessive use
- Current Relationship with Recreational or Prescription Drugs:
  
  do not usemoderate usemild useheavy useexcessive use
- Problematic History of Recreational Illegal or Prescription Drug Use:
  
  nomildmoderateheavyexcessiveOther
- Problematic History of Alcohol or Substance Use:
  
  noyes, alcohol useyes, illegal drug useyes, prescription drug useOther
- Currently Self Harming:
  
  noyesOther
- Current Suicidal Thoughts with/without a Plan:
  
  noyes, without a planyes, with a planOther
- Current Violent Thoughts with/without Plan:
  
  noyes, without a planyes, with a planOther
- History of Self Harm, Suicidal or Violent thoughts, Thoughts:
  
  noyes, self harmyes, suicidal thoughtsyes, suicidal attemptsyes, violent thoughtsyes, violets acts.Other
- Reason(s) Seeking Therapy:*
- Mitigating Strengths, Coping Skills, and/or Spiritual Beliefs:
- Explanation of Symptoms:
- Physician:
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  
  Area CodePhone Number
- Significant Health Issues:
  
  N/Aserious illnessserious injuryhospitalizationsurgeryhead injury with loss of consciousnessasthmaallergiesdiabetesepilepsyseizuresheart problemshigh feverslead poisoningspeech or language problemschronic ear infectionshearing difficultiesvision problemsfine motor problemsgross motor problemsappetite problemssleep problemsmedication induced problemsalcohol induced problemdrug induced problemother medical problemsOther
- Allergies:
  
  N/Aseasonalindoorfragrancechemical sensitivitypetOther
- Current Medications:
- Explanation of Medical Problems:
- Maritial Status:
  
  marrieddomestic partnershipdivorcedsingleOther
- Previous Marriages:
- Children:
  
  noyesOther
- Children Ages:
- Parents/Siblings Living:
  
  motherfathersisterbrothernoneOther
- Providing Care for Family:
  
  N/AmotherfathersisterbrotherOther
- Mental Health Issues with Blood Relatives:
  
  not aware of anynoyesOther
- Please explain:
- Brief Description of Relationship with your Nuclear Family:*
- Brief Description of Relationship with your Family of Origen:*
- Military Service:
  
  currentlyin pastneverOther
- Highest Education:
  
  grade schoolhigh schoolBAMAPhDOther
- School/Area(s) of Study:
- Employment Status:
  
  part timefull timeself-employeddisabilityretiredunemployed.Other
- Employer:
- Religious/Spiritual Affiliation:
- Mental Status-Appearance:
  
  not assessed.poorly groomed.strange/bizarre.unusual.well groomed.casual and clean.informal.Other
- Mental Status-Behavior:
  
  not assessed.poor eye contact.relaxed.tearful.threatening.tics.tremors.appropriate.agitated.compulsive.fidgeting.hyperactive.impulsive.laughing.lethargic.Other
- Mental Status-Mood:
  
  not assessed.hypomanic/manic.normal (bright)angry.anxious.depressed.euphoric.fearful.numb.sad.Other
- Mental Status-Orientation:
  
  not assessed.fully oriented to person, place, date, and time.completely disoriented.orriented to only person.oriented to only person and place.oriented to only place.oriented to only time.Other
- Mental Status-Attitude:
  
  not assessed.cooperative.denial /maximizing.denial/minimizing.denial/rationalizing.evasive/guarded.threatening.uncooperative.withdrawn.Other
- Mental Status-Affect:
  
  not assessed.appropriate.constricted.expansive.flat.labile.tense.Other
- Mental Status-Thought:
  
  not assessed.logical.bizarre.coherant.delusions.eccentric.flight of ideas.Other
- Mental Status-Speech:
  
  not assessed.normal.fast.loud.monotone.pressured.slurred.soft.Other
- Mental Status-Intellectual Status:
  
  not assessed.no gross impairment .above average.average.below average.borderline.deficient.Other
- Mental Status-Judgement:
  
  not assessed.no gross impairment.good.fair.poor.immature.Other
- Mental Status-Insight:
  
  not assessed.no gross impairment.good.fair.poor.immature.Other
- Mental Status-Short Term Memory:
  
  not assessed.intact.mildly impaired.moderately impaired.severely impaired.no gross impairment noted.Other
- Mental Status-Long Term Memory:
  
  not assessed.intact.mildly impaired.moderately impaired.severely impaired.no gross impairment noted.Other
- Mental Status-Fund of Knowledge
  
  not assessed.accurate.mostly accurate.inaccurate.moderately limited.severely limited.no gross impairment noted.Other
- Integrated Summary (including case conceptualization):
- Treatment Plan & Recommendations:
- Dx:
- Therapist Signature
  
  Clear
  Kila Hillman Sena, MA, LPCC
- Psychotherapist
- Date
  
  MonthDayYear
  Date
- PDF Copy (print or download for your records)
- CLIENT SIGNATURE (child's if 14 or older)*
  
  Clear
  I have read and agree to the Clinician-Patient Services Agreement
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I have read and agree to the Clinician-Patient Services Agreement
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PDF Copy (print or download for your records)
- CLIENT SIGNATURE (child's if 14 or older)*
  
  Clear
  I have read and agree to the New Mexico Notice Form
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I have read and agree to the New Mexico Notice Form.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PDF Copy (print or download for your records)
- CLIENT SIGNATURE (child's if 14 or older)*
  
  Clear
  I have read and agree to the Telehealth Consent for Treatment.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I have read and agree to the Telehealth Consent for Treatment.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PDF Copy (print or download for your records)
- CLIENT SIGNATURE (child's if 14 or older)*
  
  Clear
  I have read and agree to the Telehealth Consent for Treatment.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I have read and agree to the Telehealth Consent for Treatment.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PDF Copy (print or download for your records)
- I understand and agree that choosing to OPT IN to self-schedule my own appointments could inadvertently expose my name, email or phone number during electronic transmission, and acknowledge that if I choose to OPT OUT of self-scheduling my own appointments, then I need to contact my provider directly to schedule my appointments for me.
- CLIENT SIGNATURE (child's if 14 or older)*
  
  Clear
  I have read and agree to the Telehealth Consent for Treatment.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I have read and agree to the Telehealth Consent for Treatment.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- OPTIONAL BEHAVIORAL CARE AND PRIMARY CARE PHYSICIAN (PCP) COORDINATION OF CARE FORM
- YOU HAVE THE OPTION of releasing and exchanging your confidential behavioral health and medical information between Santa Fe Psychology, your primary care physician, and/or other healthcare practitioner's to promote the continuity and coordination of your behavioral health care and general medical care. This consent is automatically renewable each year and the confidential information that is exchanged will be kept by the recipient until such time as state law allows destruction of my patient record. This authorization may be revoked, in writing, at any time, except to the extent that any action has been taken in reliance thereon, and you legal representative is entitled to a copy of this form.
- I have read and understand the Behavioral Care and Primary Care Physician (PCP) Coordination of Care Option (do not fill out Coordination of Care Form in next section in you OPT OUT):
- INSTRUCTIONS: don't fill out this form unless you are opting to consent to Coordination of Care between Santa Feyour Primary Care Physician and/or other providers wherby your mental health records, or a portion of your records, will be exchanged with them.
- CONSENT FOR BEHAVIORAL CARE AND PRIMARY CARE PHYSICIAN (PCP) COORDINATION OF CARE FORM
- CONFIDENTIAL PROTECTED HEALTH INFORMATION ENCLOSED. Protected Health Information (PHI) is personal and sensitive information related to a person's healthcare. It is being delivered to you after appropriate authorization from the patient/member or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient/member consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law. We are sending via:
  
  MailFaxOther
- From:
  
  Kila Hillman-Sena, MA, LPCC
  
  Santa Fe Psychology
  1225 S. St Francis, Bld B
  Santa Fe, NM 87505
  
  Work Cell: (505) 919-8037
  Phone: (505) 795-5566
  Fax: (505) 930-5204
  
  Email: kila@kilahillman.net
  
  Dear Primary Care Physician/or other Healthcare Practitioner:
  
  I have seen the client named below for outpatient behavioral health treatment.
- Client Assessment is Included
- Number of sessions and dates attended:
- The client's behavioral health diagnosis is:
- Client Name:
  
  First NameLast Name
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number:
  
  Area CodePhone Number
- Date of Birth:
  
  MonthDayYear
  Date
- Social Security Number:
- Primary Care Physician (PCP)/or other Healthcare Provider (to exchange confidential medical information with):
  
  First NameLast Name
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone:
  
  Area CodePhone Number
- Office Phone:
  
  Area CodePhone Number
- Fax:
  
  Area CodePhone Number
- Additional Healthcare Provider (to exchange confidential information with):
  
  First NameLast Name
- Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone:
  
  Area CodePhone Number
- Office Phone:
  
  Area CodePhone Number
- Fax:
  
  Area CodePhone Number
- Release the following to my primary care physician/or other healthcare practitioner:
  
  Number of Sessions AttendedDiagnosisAssessmentOther
- CLIENT SIGNATURE (child's if older than 14)
  
  Clear
  I authorize the release of confidential information between Kila Hillman-Sena, MA, LPCC/Santa Fe Psychology and my primary care physician/or other healthcare practitioner.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- PARENT/GUARDIAN SIGNATURE
  
  Clear
  I authorize the release of confidential information between Kila Hillman-Sena, MA, LPCC/Santa Fe Psychology and my primary care physician/or other healthcare practitioner.
- Name
  
  First NameLast Name
- Date
  
  MonthDayYear
  Date
- Upload Pertinent Medical Documents:
  
  Upload
  
  Cancelof
- I have read and agree to the Schedulista Privacy Policy, understand that Kila Hillman-Sena, MA, LPCC with Santa Fe Psychology utilizes this scheduling system, and a PDF download was provided for your records.
- First Name
- Middle Name
- Last Name
- Preferences for Contact:
  
  allcell phoneemailhome phoneself-schedulertextwork phoneOther
- Should be Empty: