IHI Counseling Intake Form NEW

IHI Counseling Intake Form

Please fill in the form below
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please indicate if emailed invoices works for you. We generally ONLY send invoices through email. If for some reason you cannot receive and pay invoices by email/online please indicate below:*

Yes, please send invoices by email only, I can receive them and pay them online or call and pay over the phone.No, I absolutely cannot receive invoices by email or pay online and must receive all invoices via USPS.
Name of Emergency Contact*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Please enter a valid phone number.
Type of counseling you are seeking*

Individual Counseling for MyselfIndividual Counseling for A Person Under My CareCouples CounselingFamily Counseling
If you are filling this form out for someone else, what is your full name and your relationship to the client?
Which type of counseling would you prefer*

In-Person (Bothell)TelehealthUnsure
Did you find us through Open Path Collective*

NoYes
How did you hear about Inside Health Institute?*

Personal ReferralSocial Media or IHI WebsiteFlier or business cardOpen Path CollectiveProject Access NorthwestPsychology TodayYWCAVerdantOther
What is your gender identity? (Check all that apply)*

FemaleTransgender Female MTFMaleTransgender Male FTMNonbinaryIntersexCisgenderGender QueerGender Non-ConformingOther
What is your sexual orientation? (Check all that apply)*

Heterosexual (Straight)BisexualGayLesbianQueerPansexualDemisexualAsexualQuestioningOther
Preferred Pronouns*

He/Him/HisShe/Her/HersThey/Them/TheirsOther
Which race(s) do you identify as?*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latinx, or SpanishNative Hawaiian or Pacific IslanderCaucasian (White)Decline to AnswerOther
Do you currently take any medications for mental health related concerns?*

YesNo

If yes, please list your current medications for mental health:

	Name of Medication	Dose
Medication
Medication
Medication
Medication

Have you ever been hospitalized for mental health conditions?*

YesNo
Please list any current health conditions
Have you had any major surgeries?*

YesNo
If yes, please list any major surgeries and your best estimate of the date they occured
Have you ever sought counseling before?*

YesNo
If yes, please list where and when you did counseling
In the past 12 months have you considered suicide?*

NoYes
If yes, please name any triggers
Have you ever intentionally harmed yourself or attempted suicide?*

NoYes
If yes, please describe the situation and triggers
Have you ever had any legal issues now or in the past?*

NoYes

Legal Issues (please indicate current and/or past)

	Current	Past
Divorce
Custody Case
Domestic Violence
DUI
Jail Time
Prison Time

What is/are your goal(s) for counseling? *
How will you know when the goal(s) is/are met?*
Anything else you would like us to know?
Current Concerns (Check all that apply or that you want to focus on)*

Abuse: Physical/Sexual/Emotional/Financial and/or NeglectAdjusting to work or schoolAggression or ViolenceAlcohol UseAnxiety or NervousnessAnger, Hostility, Arguing or IrritabilityAssertivenessAttention, Concentration, DistractibilityBipolar DisorderCareer Concerns, Goals, and ChoicesChildhood Issues (your own childhood)CodependenceConfusionComing OutCompulsionsCustody of ChildrenDecision Making/Indecision, Mixed Feelings, Putting Off DecisionsDelusions (False Ideas)DependenceDepression, Low Mood, Sadness, CryingDivorce, SeparationEating Problems - Overeating, Undereating, Appetite, VomitingEmptinessFailureFatigue, Low EnergyFearsFriendshipsGrievingInterpersonal ConflictsImpulsivenessCouple’s ConflictMotivationObsessions or CompulsionsOppressionPanic or Anxiety AttacksParentingPerfectionismProcrastinationPTSDSelf-EsteemSleep problemsStressSuicidal ThoughtsSubstance Use- Prescription, Over-the-Counter, and/or Street SubstancesTraumaOther
Please indicate which counselor you are a new client of*

Leah BrownEmmalee BozekMark EngelbergGrace BicketTara NairMaggie ButlerMegan WilsonElizabeth WrightCasey PhelpsRebecca WendfeldtJustin ThompsonEileen BowenSasha MelnikAngela WhitneyMichael PerryIsabela CarvajalTorry AndersonLakshmi SithambaramNot Assigned Yet

Clinic Policies for Inside Health Institute & Clinician Disclosure

Please read carefully
Fees

Office Visits: Fees for appointments are determined by the client through a "Pay-what-you-can" tiered rate, presented to them as options during the in-take process. Further reduced rates may be available on a case-by-case basis. Please arrive on time for your visits in order to ensure you and your clinician can take advantage of the full time of your session. If you need help with directions or accessing online appointments, please contact us at info@insidehealthinstitute.org or call 425-256-2125.

Insurance: We are out-of-network with all insurance companies. All visits are client pay and are not billable through insurance. If you need a coded bill to submit to insurance for reimbursement, our team may be able to provide you with one.

E-Mails: It is preferable that clients and clinicians communicate through our secure portal, Charm, rather than communicating by text or email directly with your clinician. Messaging or email should not be used for sole case management. If you need help accessing Charm or communicating with your clinician, please email info@insidehealthinstitute.org or call 425-256-2125.

Copies/Administrative Fees: If you need copies of chart notes or anything else, we will ask for payment to cover any expense to the clinic. Fees will be variable depending on the extent of the request. This does not include the complimentary printing of a few pages of information that your clinician may want to share with you but, rather, applies, to requests to do printing or copying that is outside of the normal client/clinician visit.

Appointment cancellations: Any no-show appointments or appointments canceled without 24-hour notice will be billed your full visit fee. These fees will be the patient’s responsibility.

Payment: Payment is made in person or through an invoice that will be emailed to you after your visit. Inside Health Institute accepts checks, cash, and credit cards (Visa, Mastercard, and Discover). Invoices and receipts are available by request. If you are experiencing financial hardship and need help making payments or need help with adjusting your fee or account balance, please contact us at info@insidehealthinstitute.org or call 425-256-2125 for help.

Returned Check Fee: There is a $25 fee for each returned check.

All fees are subject to change and patients will be kept abreast of these changes. If you have any questions regarding these guidelines please feel free to ask.
I have read and agree to the above clinic practice. I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Inside Health Institute regarding cure or improvement of my condition. I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by my representative or me otherwise permitted or required by law.
Signature*

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Relationship to client if you are not the client

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read carefully.
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may disclose your health information.

We may use and disclose your medical records only for each of the following purposes:
- Treatment, payment, and health care operations.
- Treatment means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. An example of this would include a physical examination.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to an insurance company for payment.
- Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
- The right to reasonable requests on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
- The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
- The right to inspect and copy your protected health information.
- The right to amend your protected health information.
- The right to receive an accounting of disclosure of protected health information.
- The right to obtain a paper copy of this notice from us upon request
  We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of June 10, 2002, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post on our website, and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with our office or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies or procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information, by asking to speak to our Privacy Officer or for written inquiries, note “Attention Privacy Officer.”

Or to file a complaint:

The U.S. Department of Health and Human Services Office of Civil Rights
200 Independence Ave. S.W.
Washington D.C. 20201

(202) 619-0257 Toll Free: 1-877-696-6775
Acknowledgement Of Privacy Practices

Eileen Bowen, MA, LMHC, GMHS License #: LH60273538 Licensed Mental Health Counselor & Geriatric Mental Health Counselor. Director of Counseling and Supervisor of all interns at IHI.
Eileen Bowen, MA, LMHC, GMHS is required to provide you with a copy of her “Notice of Privacy Practices” document, and to obtain written acknowledgment, if possible, that you have received it.

The notice outlines the types of uses and disclosures that may occur involving your protected health information. It also describes your rights and explains how you may exercise those rights.

I understand that my protected health information can and will be used to:

• Provide and coordinate my treatment among healthcare providers

• Obtain payment from third-party payers for my health care services.

• Conduct normal healthcare operations such as quality assessment and improvement activities.

I understand that my provider has the right to change the Notice of Privacy Practices and that I may request a current copy at any time.
My signature below acknowledges that I have (Please check one box)

Been offered a copy of the “Notice of Privacy Practices” document and have accepted that copy. (We will email you a copy if you choose this option)Been offered a copy of the “Notice of Privacy Practices” document and have declined to take a copy. I understand that I may request a copy at any time in the future, and will be granted a current copy upon request
Signature*

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IHI Counseling Intake Form

Clinic Policies for Inside Health Institute & Clinician Disclosure

Notice of Privacy Practices

Acknowledgement Of Privacy Practices