Client Intake and Service Consent
Therapeutic counseling is a collaborative effort between the client and mental health professional, who provides a supportive and non-judgmental environment to help clients address challenges and achieve their goals. This informed consent document outlines the counseling services, benefits, risks, and client rights. Each therapy experience is unique to the individual. Before your first visit, we need to gather some general information from you.
Name
*
First Name
Last Name
Date of Birth (mm/dd/yyyy)
*
Gender Identification
*
Place of Birth
*
Please Select
American Samoa
Samoa
United States
Other U.S. Territory
Other Country (specify)
If you selected "Other Country" or "Other U.S. Territory," please specify:
Ethnicity
*
Please Select
Samoan
Tongan
Native Hawaiian
Chamorro / Guamanian
Marshallese
Other Pacific Islander
Asian
White / Caucasian
Black / African American
Hispanic / Latino
American Indian / Alaska Native
Multiracial
Other (specify)
Prefer not to answer
U.S. Military Veteran Status
*
Yes
No
Employment Status
Please Select
Full-time
Part-time
Unemployed
Student
Retired
Transportation Access
Please Select
Reliable transportation
Limited transportation
No transportation
Presenting Concern/Issue
Please Select
Depression
Anxiety
Stress
Trauma
Grief/Loss
Family Conflict
Relationship Concerns
Anger Management
Emotional Regulation
Substance Use
Suicidal Thoughts
Suicide Attempt History
Self-Harm
Domestic Violence
Sexual Assault
Child Abuse
Parenting Concerns
School Concerns
Work-Related Stress
Other
If you are unsure on the presenting concern(s) or if it's not listed above, please describe or elaborate.
Parent(s) / Legal Guardian(s) (if under the age of 18)
Parent 1 or Legal Caretaker 1
Parent 2 or Legal Caretaker 2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
*
Full name
Relationship
Emergency Contact Phone
*
Referral Source
Please Select
Self-Referral
Department of Health - Behavioral Health
LBJ Hospital
Emergency Department
School
Court/Probation
Child Protective Services
Adult Protective Services
Domestic Violence Program
Substance Use Program
Employer
Family/Friend
Other
Are you currently required by a court, probation officer, parole officer, or other legal authority to participate in mental health counseling or services?
*
Yes
No
Unsure
Not Applicable
COUNSELING SERVICES
I understand that I will be receiving counseling services from a mental health professional with Tautua Mental Health. Counseling services may include individual, couple, or group therapy sessions. The purpose of counseling is to address my mental, emotional, behavioral concerns and to help me develop strategies to manage my symptoms and improve my overall well-being.
Type Your Initials to Agree to Counseling Services
*
Initials
CONFIDENTIALITY
You understand that information shared during counseling is confidential. Confidentiality may be limited in specific situations. If you are assessed to be a danger to yourself or to others, your mental health provider may take action to protect you or others who may be at risk. If there is reasonable suspicion of child abuse, elder abuse, or abuse of a dependent adult, your mental health provider is required by law to report this to the appropriate authorities. If you sign a valid release of information, your mental health provider may share relevant information with healthcare providers, family members, or other individuals you authorize. You understand that your mental health provider may consult with other healthcare professionals or supervisors when necessary to support your care.
Type Your Initials to Agree to Confidentiality Terms
*
Initials
LIMITS OF COUNSELING SERVICES
I understand that counseling is not a substitute for medical or psychiatric treatment, and my mental health provider is not a medical doctor or psychiatrist. If my mental health provider believes I need medical or psychiatric treatment, they may refer me to a medical doctor or psychiatrist. I understand that counseling is not a guarantee of specific results or outcomes and that I am responsible for my own progress and success in counseling.
Type Your Initials That You Have Read and Acknowledge the Limits of Counseling Services
*
Initials
RISKS AND BENEFITS
I understand that counseling may involve discussing difficult or unpleasant topics, and that I may experience uncomfortable emotions during counseling sessions. However, I also understand that counseling may help improve my coping skills, develop stronger relationships, and achieve my goals.
Type Your Initials That You Have Read and Acknowledge the Risks and Benefits of Counseling.
*
Initials
Referral and Consent Disclosure
By signing below, you confirm that the information provided is accurate and that consent has been obtained for referral and mental health services with TAUTUA. Client signature confirms a voluntary request for services. Parent or legal guardian signature is required for clients under the age 18. Referral agency signature confirms authorization to submit this referral on behalf of the client after consent has been obtained.
Signature
*
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