Client Intake Form

Client Intake Form

The following questions are designed to help me best meet your needs. If the person seeking care is a minor, the parent or guardian should complete the form. If you have any questions, I will be happy to answer them.
Client Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Mobile Phone*
Please enter a valid phone number.
Employer
Position
How long at this position?
Education
Marital / Relationship Status
Significant Other’s Name (If Any)
Significant Other’s Age and Gender
How Long Together
Names and Ages of All Your Children
Referred by (If Any)
Emergency Contact
Emergency Contact Phone
Emergency Contact Relationship
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

YesNo
Previous therapist/practitioner
Are you currently taking any prescription medication?

YesNo
Please list:
Have you ever been prescribed psychiatric medication?

YesNo
Please List and Provide Dates:
List any substance abuse treatment or inpatient psychiatric treatment you have had, and the dates:
Please list any difficulties you experience with your appetite or eating patterns:
Are you currently experiencing overwhelming sadness, grief or depression?

YesNo
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias?

YesNo
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?

YesNo
If yes, please describe:
Do you drink alcohol more than once a week?

YesNo
How often do you engage in recreational drug use?

DailyWeeklyMonthlyInfrequentlyNever
Are you currently in a romantic relationship?

YesNo
If yes, for how long?
On a scale of 1-10 how would you rate your relationship? (10 being the best)
What significant life changes or stressful events have you experienced recently?

Please indicate if you are having any of the following problems, or if you had them in the past:

	Yes	No	Other
Falling asleep or staying asleep
Sleeping too much
Change in appetite, weight loss, or weight gain
Frequent crying
Panic attacks or anxiety attacks
Thoughts of killing or hurting myself
Attempts to kill or hurt myself
Concentrating
Problems remembering things
Periods of daily sadness lasting more than two weeks
I startle easily
Can’t stop remembering upsetting past events
Difficulty controlling my temper
I physically hurt other people
I break things sometimes
I worry a lot
Little or no interest in sex
I feel tired almost every day
Feelings of unreality
Made myself throw up in order to lose weight
Used laxatives or exercised excessively to lose weight
I often feel like I am an outsider
Sexual problems
Worry that something is wrong with my body
Frequent arguments with the people I live with
Other (please list):

Family Medical and Health History:

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you (father, grandmother, uncle, etc.).

Please check the applicable box(es):

	Yes	No	Relationship
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts

Any other information you would like to share:
I, {clientName}, hereby consent for Dr Mona Shenassa Toubian to provide evaluation and treatment to me.
Client Name*

First NameLast Name
Today's Date

MonthDayYear
Date
Signature*

Clear

Confidentiality Agreement
CONFIDENTIALITY AND PRIVILEGED COMMUNICATION REMAIN THE RIGHTS OF ALL CLIENTS OF PROFESSIONAL COUNSELING ACCORDING TO LAW. Everything will be done within the constraints of the law and professional guidance to maintain each and every client’s full confidentiality by the Therapist.

In a group therapeutic setting it is also mandatory that each client commits to maintain the confidentiality of every other client in the group, and does not discuss what is shared within the group setting with anyone outside of the group.

However, with respect to the Therapist, there are some limits which are mandated by state law. It is very important that you and those seeking counseling with you carefully read and understand the following.

Duty to Warn
Some courts have held that if an individual intends to take harmful, dangerous, or criminal action against another human being, or against himself or herself, it is the counselor's duty to warn appropriate individuals of such intentions. Those warned may include a variety of persons such as:1. The person or the family of the person who is likely to suffer the results of harmful behavior. 2. The family of the client who intends to harm him/herself or someone else. 3. Associates, friends of those threatened or making threats. 4. Law enforcement and medical emergency officials.

Child Abuse
California state law mandates the reporting of incidence of or suspected incidence of child abuse, including physical abuse, sexual abuse, unlawful sexual intercourse, neglect, emotional and psychological abuse. All actual or suspected acts of child abuse should be reported to the appropriate agencies. (Article 2.5 Penal Code 11165 and 11166)

"Dependent Adult" and Elderly Abuse
California law requires the incidence of "dependent adult" or elderly physical abuse to be reported to California authorities. (Welfare and Institution Code, Sec. 15630)

Therapeutic Criminal Involvement
The State Law in the Evidence Code 1018 reads that "There is no privilege (confidentiality) under this article if the services of the psychotherapist were sought or obtained to enable or aid anyone to commit or plan to commit a crime or a tort or to escape detection or apprehension after the commission of a crime or a tort." (Evidence Code 1024, 1965. Chp. 299)

Family and Couple Therapy
Family members and couples may be seen at times individually or conjointly. Information shared during these sessions or in related settings (e.g. telephone calls) is considered part of the overall family or couple therapy process and is not confidential from the other participating family members or partners. The therapist will use discretion in handling these matters. It is important that you, the client, understand this policy before treatment begins. Healthy relationships are built on openness and truth.

Cancellation Policy
If you are a no-show or otherwise fail to cancel a scheduled appointment with at least 24 hours prior notice, I cannot use this time for another client and you will be billed respectively for the entire cost of your missed appointment. A bill will be mailed directly to all clients who do not show up for, or appropriately cancel an appointment with at least 24 hours prior notice.

Neglect of Outstanding Debt
In the event that a client fails to honor, after reasonable efforts to collect; his/her debt, the account may be referred to an agency or attorney for collection or legal action. This will necessitate the release of pertinent demographic information as well as accounting information (no therapeutic information will be released).

Please be sure that you have read the above very carefully. If you are not sure that you fully understand any of the above, please ask your counselor before you sign below.

I/We have read and fully understand the limits of my/our confidentiality and the other information outlined above. I/We further agree to abide by the policy set out above. I/We have had a chance to ask my/our Therapist for additional clarification regarding the limits of confidentiality.

{clientName}
Signature*

Clear
Date*

MonthDayYear
Date

Are you interested in applying for the "Women’s Therapy Groups" program?

YesNo
Women’s Therapy Groups (Virtual)

Mona holds that every woman has the power to connect to her intuition, overcome challenges in her life and actualize her highest potential. That is why Dr. Mona Shenassa Toubian shares her therapeutic methodology called Soul Work Evolution™ — which has transformed the lives of many women.
Registration is now open for Women’s Soul Work Evolution™ Therapy Groups.

There are 4 groups with spots available:
Please drag and drop the following group to rank your preference (please pick your first, second and third option, as there is a possibility that your first or second choice may be full.):
Credit Card Authorization for Group Therapy Work
I, {clientName} authorize Dr. Mona Shenassa Toubian to charge my credit card for any services rendered as agreed to. I also authorize MST International Inc. to charge my card in the event I fail to show for a scheduled appointment, or do not give notification of my inability to attend a scheduled appointment at least 72 business hours in advance. I further authorize MST International Inc. to disclose information about my attendance/cancellation to my credit card company if I dispute a charge. I acknowledge that I am aware there is a $25 fee for any declined credit card charge (or $35 for a bounced check).

* I agree to have my credit card automatically authorized for $650/month for the group therapy sessions. There will be no prorated or deducted fees for 2 hour weekly sessions that are missed.
** I agree to a three-month commitment in order to maintain optimal cohesiveness and benefit to the group members.
*** Dr. Mona does not take insurance directly but works with “Advekit” which is a platform that can help you understand and use your Out-of-Network insurance benefits. If you make a free account with this service, they will link you with me and will pay me on your behalf. Advekit will only charge you the balance of what your insurance does not pay. So, once you meet your deductible, they only charge you what you owe and they wait for reimbursement instead of you having to wait. This also means that you will no longer have to file insurance claims or paperwork because they will do it for you! Their goal is to make it easier for both of us so we can focus on your care. There is 12% transaction fee added to price for using this option which Advekit charges.

*Cancellations must be made at least 72 hours in advance or fee must be paid in
full and I am aware there is a $25.00 fee for declined credit cards (or $35 for a
bounced check). This form will be securely stored in your clinical file and may be updated upon request at any time. Please note, your credit card will not be charged unless the following conditions apply: Therapy session was attended by you, the client, or you were a no-show for a scheduled appointment, or you failed to cancel less than 72 business hours in advance, allowing us to reschedule other clients in the
session slot.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Client Intake Form

Family Medical and Health History:

Confidentiality Agreement

Women’s Therapy Groups (Virtual)

Credit Card Authorization for Group Therapy Work