ADULT CLIENT INTAKE

ADULT CLIENT INTAKE / FACE SHEET
CLIENT INFORMATION
Full Name*
Weight*
Height*
Age*
Date of Birth*

MonthDayYear
Date
Eye Color*
Insurance Company*
Address*
Current Residence*
Insurance ID Medicaid*
Home Phone*
Cell Phone*
Work Phone*
Email*
example@example.com
Marital Status*
Gender*
Student Status*
Race Ethnicity*
Occupation Employer*
Need Interpreter*
Preferred Language*
If yes details*
Received mental health services before*
Reason for Seeking Services Presenting Issues*
EMERGENCY CONTACT INFORMATION
Relationship*
Name*
Phone Number*
MEDICAL HISTORY QUESTIONNAIRE
Allergies to medications*
If yes list details*
Taking medications*
If yes which*
Other allergies*
Primary Care Physician (Name & Phone)*
Last PCP visit reason*
Current medical conditions*
If female PregnantUnsure*
Conditions interfere with daily life*
CONSENT FOR TREATMENT
I hereby consent to receive treatment through Safe Place Counseling. I understand that: 1. My clinical, administrative, and billing information may be collected and stored for treatment, claims, and statistical purposes. 2. My records will be maintained confidentially, with disclosure only as required by law, third-party payers, emergencies, court orders, or with my consent. 3. I agree to satisfy any financial obligations for services rendered.
Signature*

Clear
Date*

MonthDayYear
Date
CONSENT FOR TELEHEALTH / SERVICES (If applicable)

By checking below and signing, I understand and agree to the use of telehealth services, including the potential risks (e.g. privacy breaches), and my rights with respect to refusing or withdrawing consent.

No I consent to telehealth services:Yes Signature:
Signature*

Clear
Date*

MonthDayYear
Date
CLIENT RIGHTS & RESPONSIBILITIES
Clients have the right to confidentiality, nondiscrimination, participation in treatment planning, and to file grievances. Clients are responsible for attending scheduled sessions, being honest with staff, and respecting the therapeutic process.
Signature Acknowledgement*

Clear
Date*

MonthDayYear
Date
HIPAA / PRIVACY NOTICE ACKNOWLEDGMENT
I acknowledge that I have received a copy of the Notice of Privacy Practices from Safe Place Counseling and understand how my personal health information may be used and disclosed. I understand my rights concerning my health information, and how to file a complaint if I believe my
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

ADULT CLIENT INTAKE / FACE SHEET

CLIENT INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL HISTORY QUESTIONNAIRE

CONSENT FOR TREATMENT

CLIENT RIGHTS & RESPONSIBILITIES

HIPAA / PRIVACY NOTICE ACKNOWLEDGMENT