NEW PATIENT FORM: COUNSELING

NEW PATIENT FORM: COUNSELING
Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Best contact number
Email*
example@example.com
Is it ok to email you?*

YesNo
Emergency contact name and number *
Relationship to you*
Chronic Pain & General Health Information
Have you ever experienced any of the following as a result of your chronic pain? (Check any that apply)*

anxietyfearsleep disturbancescrying spellsdepressionavoidance of activities that cause painirritability or angerfatigue/low energynone of the above
Does anyone else in your family have chronic pain?

YesNo

Rate the following by placing a mark in the most appropriate box. *

	Excellent	Very good	Good	average	Poor
Overall physical health
Overall mental health
Diet
Exercise routine
Sleep
Relationships

Have you ever sought counseling for chronic pain before?*

yesno

Confidentiality Agreement
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing this document at the bottom.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy for chronic pain. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings. There are no miracle cures; however, I can promise to support you and do my very best to understand you, point out any patterns of behaviors that are holding you back, as well as help you clarify goals that you want for yourself.

Confidentiality

The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below. Under these circumstances, I would have to break confidentiality:

1. If you threaten or attempt to commit suicide or otherwise conduct yourself in a manner in which there is a substantial risk of you incurring serious bodily harm.

2. If you threaten grave bodily harm or death to another person.

3. If I have a reasonable suspicion that you or another named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If you are in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Public settings

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Social media

For ethical reasons, I am unable to accept you as a friend on Facebook or follow you on other social media platforms such as Twitter and Instagram. As a counselor, I cannot be your friend and your therapist as this blurs boundaries. This rule is also in place to protect your confidentiality and so that we can have an effective therapeutic relationship. Social media often reveals details about people that would not necessarily be discussed in therapy. Having access to this level of detailed personal information can significantly affect the therapeutic alliance on both sides.
I First Name* Last Name* have read the confidentiality agreement and agree with everything stated.
Signature*

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Date*

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NEW PATIENT FORM: COUNSELING

Chronic Pain & General Health Information

Confidentiality Agreement