Patient Intake

1

Please verify that you are human* This field is required.

2

Are you completing these forms for yourself or a child?* This field is required.(Required)

For Myself

For My Child

For a Child I'm a Guardian of

3

Will Safe Haven Arts be providing individual or group sessions to the patient?* This field is required.

Individual

Group

Both

Not sure

4

What is the patient's name?* This field is required.(Required)

First Name

Last Name

5

What is your name as Guardian?* This field is required.(Required)

First Name

Last Name

6

What is your home address?* This field is required.(Required)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

7

What is your email address?* This field is required.(Required)

example@example.com

8

What is the patient's date of birth?* This field is required.

9

What is the patient's gender?

Male

Female

Non-binary

Prefer not to say

10

What is your mobile phone number?* This field is required.

Please enter a valid phone number.

11

(Optional) What is your home phone number?

Please enter a valid phone number.

17

Additional comments about behavior, attitude or challenges.

18

Has your child's teacher, counselor, pediatrician or other related care professional recommended a Social Skills group?Intake forms with recommendations/referrals will be considered prior to those without.

YESNO

19

Child's prior therapist information- release required before contact

20

Has there been a prior diagnosis? Fill in any details below

21

List current prescribed medications and dosage .Fill in any details below

22

Your Emergency Contact Name, Number and Relationship* This field is required.

Emergency Contact Name

Phone Number

Relationship

Your Emergency Info

Emergency Contact Name

Phone Number

Relationship

23

Name and Phone Number of Primary Care Physician

24

Are you under the care of a psychiatrist?* This field is required.

YESNO

25

Name and Phone Number of Psychiatrist

26

Local Hospital Name and Number* This field is required.Required by Louisiana Licensed Professional Counseling Board

27

Local Police Branch Name and Number* This field is required.Required by Louisiana Licensed Professional Counseling Board

28

Is the patient covered by health insurance?(Required)

YESNO

29

What insurance company provides your insurance coverage?

30

Does your insurance policy cover or reimburse for out of network providers?

Yes

No

Not sure

Reimbursement

31

GOOD NEWS!

We can accept cash payments. We'll discuss when we talk.

32

Do you want to upload your insurance card or fill in insurance information?* This field is required.Please upload BOTH front and back sides of the insurance card!

Upload CardFill in Information

33

Upload your insurance card* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

34

Did you upload the back side of your insurance card, too?(Required)

YESNOT YET

35

Upload the back side of your insurance card* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

36

Insurance Plan Information* This field is required.

37

Do you have any other health benefit plans?* This field is required.

YESNO

38

For the additional health insurance coverage, do you want to upload your insurance card or fill in insurance information?* This field is required.

Upload CardFill in Information

39

Upload your additional insurance card* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

40

Did you upload the back side of your insurance card, too?(Required)

YESNOT YET

41

Upload the back side of your additional insurance card* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Browse Files

42

Additional Insurance Plan Information* This field is required.(Click Back to change your answer to No if you don't have additional insurance.)

43

Insurance Reimbursement for Group Sessions* This field is required.

44

Insurance Assignment Terms and Conditions* This field is required.

45

Client-Counselor Service Agreement* This field is required.

46

Consent for Online Therapy Services* This field is required.While you may be interested in in-person session, our patients occasionally wish to have online sessions from time to time. Accordingly, we require that you consent to online therapy services. Please review the Consent Agreement below and check the box when you have read the agreement.

47

Group Participation Agreement* This field is required.I agree that my own behavior and attitudes are my responsibility as a fellow participant in a group session and if, for any reason, I become unable to do so I will remove myself from the group/meeting. The group facilitator reserves the right to block group members and discontinue access if someone’s actions do not meet the requirements below. If there is a problem with a written guideline or another group member, please address privately with the facilitator.

I agree to participate as a constructive and conscientious group-member and I will respect myself and others during this shared time

I will utilize materials in a safe manner and I will respect the boundaries of others (regarding discussion and artwork)

I will be an attentive listener and share what and when I feel comfortable and I understand that discussion during art-making is permitted as long as it is not disruptive

I will keep yourself and what I am working on visible to others in the group (and, when participating in an online session, will keep my camera visible)

If I need individual assistance I will request to speak separately by indicating that I wish to have a separate discussion, and there is no right or wrong way to create in sessions

I understand that I are participating for my own benefit and that comparisons are not helpful, and I want to have fun and be supportive

48

Optional Authorization for Release of InformationI understand that I need not consent to the release of information in order to obtain services. I choose to do so willingly and voluntarily for the purpose(s) specified below. The duration of this authorization is for one year unless I specify a date, event or condition upon which it will expire sooner. I understand that I my revoke this consent at any time by notifying Lorraine Murphy, LPC, LCAT in writing, except to extent that this action has been taken on reliance on my consent. The following information that may be disclosed includes (select all that apply, or email lorrainemurphy@safehavenarts.com if you have any questions):

Whether the patient is in treatment or not

Prognosis (diagnosis, opinion of. how treatment will benefit patient, general peculiarities of case)

Nature of the treatment/group (Services offered, purpose and philosophy)

Brief statement regarding progress (patient's denial/defenses or availability for treatment, patient's understanding of their condition/insight, progress or lack of progress on goals, cooperation with treatment plan

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Optional Authorization for Release of Information (continued)On the prior page you identified the type of information that may be shared. Below you will select the purposes for which it can be shared (select all that apply, or email lorrainemurphy@safehavenarts.com if you have any questions). My information described on the prior section may be shared for the purposes of:

Referral to other services

Coordination of care

Consultation with Doctor

Consultation with other mental health provider

Transfer of care

Other

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Optional Authorization for Use of Artwork* This field is required.I understand that I need not consent to the release of any artwork that I may create during the course of my treatment in order to obtain services. I understand that this authorization is for the purpose of furthering the field of art therapy and increasing mental health awareness. Safe Haven Arts therapists have taught as professors and intend to continue in the classroom, in trainings, through publishing about successful interventions and learned experiences, and supervising up-and-coming art therapists. In order, to do this effectively, Save Haven Arts will need access to examples of creative projects and artwork that represents the best of what is possible. Please understand that confidentiality rules still apply; actual names will not be used to protect artists’ privacy. My information described on the prior section may be shared for the purposes of:

I give consent for my creative pieces/artwork to be viewed or photographs for reasons including artistic appreciation, education presentations, research or training. I give permission for photographs of the artwork to be published for similar purposes in the future. I understand that information regarding the identity of the artist will be omitted/disguised to maintain confidentiality.

I do NOT give consent for my creative pieces/artwork to be seen or photographed for reasons which include: artistic appreciation, educational presentations, research or training. I understand that my selection may be changed/updated at any time by request.

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Signature