Therapy Intake Form

Client Intake Form
Personal Information
Full Name*

First NameLast Name
Preferred Name

First NameLast Name
May I leave a message?
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Gender*
Race:
Ethnicity
Employment
Religious Affiliation
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Emergency Contact
Emergency Contact Phone Number
Primary Care Provider
Primary Care Provider Phone Number
PCP Release of Information (ROI)*
How were you referred to our office?

Financial Information
How I plan to pay for treatment:*

I plan to use my credit/debit cardI want to pay cashI plan to use my insurance benefits

History of the Present Problem
What brings you to counseling at this time? Is there something specific?
Have you ever had the same or a similar problem?

YesNo
If yes, please describe in detail the issue you named above:
Have you ever experienced mental health symptoms before?
Has anyone in your family ever experienced mental health or substance use issues?
List your family members. What is your relationship like with them?

Social History
Do you do any of the following? (Please check all that apply)

ExerciseUse tobacco productsConsume caffeineSleep well at nightDrink alcoholTake vitamin supplements
If you checked any of the options above, please detail below:
What are your hobbies?
What spiritual practices and cultural influences are important to you?
What was life like as you were growing up, both at home and in school? Did you meet developmental milestones on time or experience delays?
Describe your current living situation. Do you live alone, with others, with family, etc.

What is your level of education? Highest grade/degree and type of degree.
What is your current occupation? What do you do? how long?

What are your goals for therapy?
As we walk this journey together. What strengths and abilities are you bringing to the sessions? What needs and preferences do you have that will help us be successful?
What else would you like me to know?
The Therapy Process
Therapy is a process that focuses on growth and change. Talking about your issues and understanding your feelings paves the way to becoming more aware of the source of your struggles and painful feelings. As we grow and change our thoughts processes we develop an awareness that allows us to consider and create new/different options in our lives.

However, it is your commitment to identifying personal goals which you desire to achieve and conquer obstacles along your journey. You determine how successful therapy will be for you by being transparent and trusting the process.

If you have a crisis situation develop after hours, call the suicide prevention hotline at (988) or go to your local emergency room.

The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require ethical and legal commitment to the confidentiality of your Personal Health Information.
Legal Responsibility
Under the laws of the United States and the state of North Carolina your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.
Use and Disclosure of your Personal Health Information (PHI)
Under the laws of the United States and the state of North Carolina your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.
Communication

We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website; you can be assured that it will only be used in accordance with this privacy statement.

We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.

DTA Wellness and Counseling Services ® Telehealth Informed Consent

Introduction of Telebehavioral Health:

As a client receiving behavioral services through telebehavioral health technologies at DTA Wellness and Counseling Services, I understand that:

Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video, or other electronic communications) between a practitioner and a client who are not in the same physical location.

The interactive technologies used in behavioral health incorporate network and software security protocols to protect the confidentiality of client information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Software Security Protocols:

Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and will include measures to safeguard health information to ensure its integrity against intentional or unintentional corruption.

Benefits & Limitations:

This service is provided by technology (including, but not limited to, video, phone, text, apps, and e-mail) and may not involve direct face-to-face communication. There are benefits and limitations to this service.

I understand that I may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telebehavioral health in my care, but that no results can be guaranteed or assured.

Technology Requirements:

    I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided.

Exchange of Information:

    The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery.

    During my telebehavioral health consultation, details of my medical history and personal health information may be discussed with myself or other behavioral health care professionals through the use of interactive video, audio, or other telecommunications technology.

Local Practitioners:

    If a need for direct, in-person services arises, it is my responsibility to contact practitioners in my area, providers referred to me by my telebehavioral health provider, or to contact my behavioral practitioner’s office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office.

Self-Termination:

    I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.

Risks of Technology:

    These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.

Modification Plan:

    My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon and modify our plan as needed.

Emergency Protocol:

    In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means.

DTA Wellness and Counseling Services, PLLC does not offer behavioral health emergency or crisis management services. As part of your mental health treatment plan, community options for mental health crisis management will be discussed on an individual basis. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

Payment for Telehealth Services:

DTA Wellness and Counseling Services, PLLC will bill insurance for telehealth services when these services are determined to be covered by an individual’s insurance plan. In the event that insurance does not cover telehealth, the individual wishes to pay out-of-pocket, or when there is no insurance coverage, we will provide you with a statement of service to submit to your insurance company if you wish.

Client Consent to the Use of Telehealth:

    I have read and understand the information provided above regarding telebehavioral health services. I understand the risks and benefits related to the use of telebehavioral health services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein.
For Questions, Concerns or Complaints
You may contact the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

Signature and Submission
Please type your name below to indicate consent to treatment.
Patient's Signature*
Date*

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature
Date

MonthDayYear
Should be Empty:

Client Intake Form

Personal Information

Financial Information

Insurance Information

Personal History

History of the Present Problem

Social History

The Therapy Process

Legal Responsibility

Use and Disclosure of your Personal Health Information (PHI)

For Questions, Concerns or Complaints

Signature and Submission