Counseling Intake Packet

Counseling Intake Form
Welcome to A New Leaf Therapeutic Services!

We’re excited to help you begin your journey with us. This form combines your screening and intake paperwork so everything can be completed in one place. It usually takes about 10–15 minutes.

Before you begin, please have the following ready:
- A valid photo ID
- Your insurance card (if applicable)
- Any legal paperwork related to custody or guardianship
Once submitted, our administrative team will verify insurance and assign a clinician. We’ll contact you within two business days to guide you through the next steps.

If we’re unable to reach you after three attempts during the intake process, we’ll assume you’ve chosen not to continue and will send you a list of other providers who may fit your needs.

Need help while completing this form?
Call us at 910-493-3555 during office hours (Mon–Fri, 8:30 AM–5:30 PM EST), or stop by to meet our team in person.

✅ Please note: Once you start, you’ll need to complete this form in one sitting.
I understand this form contains required information for treatment.*

Yes, I understand.

The Therapy Process

Participating in treatment can result in a number of benefits to you, including a better understanding of your personal goals and values, improved interpersonal relationships, and resolution of the specific concerns that led you to seek treatment. Working toward these benefits, however, requires effort on your part and may result in your experiencing some discomfort. Change will sometimes be easy and swift, but can be slow and frustrating. Remembering and resolving significant life events in treatment can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, your children and other individuals can also lead to discomfort and may result in changes that were not originally intended.
Client Right's
1. You have the right to a confidential relationship with your therapist. Within certain legal limits (see #3 below), information revealed by you during the course of treatment will be kept completely confidential and will not be revealed to any person without your written permission.
2. You have the right to know the content of your records at any time and I have the right to provide you with the complete records or a summary of their content.
3. If you ask me, I can release any part of your records on file to any person you specify in writing. I will tell you when you make your request whether or not I think releasing that information to that agency or person might be harmful to you.
4. Under certain legally defined situations, your clinician has the duty to reveal information you tell him/her during the course of treatment to other persons without your written consent. Your clinician is not required to inform you of their actions if this occurs. These legally defined situations include:
  1. Revealing active child abuse or neglect. If a perpetrator is in contact with minors and there is a reasonable suspicion that they may still be abusing minors, and/or active physical abuse of a dependent adult or an elder is taking place.
  2. If you seriously threaten harm or death to another person, clinicians are required to warn the intended victim and notify the appropriate law enforcement agencies.
  3. If you seriously threaten self-harm or suicide, clinicians are required to take necessary steps to ensure your safety, which may include notifying appropriate medical or mental health professionals, your emergency contact, and/or relevant authorities.
  4. If you are in treatment or are being tested by order of the court, the results of the treatment or tests ordered must be revealed to that court.
  5. If a court of law issues a legitimate subpoena, A New Leaf Therapeutic Services, PLLC is required by law to provide the information specifically described in that subpoena.
  6. If you are in a lawsuit claiming emotional harm, the opposing side may subpoena your treatment records.
5. You have the right to ask questions about any of the procedures used in the course of your treatment.
6. Should you choose not to enter treatment with A New Leaf Therapeutic Services, PLLC, you will be provided with names of other qualified professionals whose services you might prefer.
7. You have the right to terminate treatment with A New Leaf Therapeutic Services, PLLC at any time without any financial, legal, or moral obligations other than those you've already incurred. The therapist’s right to terminate treatment with you is listed under the section titled “Clinician Right to Discontinue Treatment” later in this document.
8. You have the right to treatment, including access to medical care and habilitation services, regardless of your age or the nature or severity of your mental health, intellectual/developmental disability, or substance use diagnosis. A New Leaf Therapeutic Services, PLLC is committed to nondiscriminatory, person-centered care and will assist you in accessing appropriate services, whether within our practice or by referring you to other providers when needed.
I understand and wish to continue.*

Yes, I understand.

Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you 18 years or older and legally able to make your own decisions, or are you a parent/legal guardian completing this form for a minor or someone under guardianship?*

Yes, I am 18 or older and can legally make my own decisions.No, I am completing this form as a parent/legal guardian for a minor or someone under guardianship.

Parent/Guardian Information
I, Last Name* First Name* , the undersigned parent/legal guardian of, Client's First Name* Client's Last Name* , authorize and request that A New Leaf Therapeutic Services PLLC, to carry out a clinical assessment, diagnostic procedures, and/or treatment which now or during the course of his/her care as a patient are advisable. I understand that if the minor is an adolescent, the content of his/her private session will also remain confidential. However, general directions the minor is taking in treatment and how I may be able to maximize his/her positive growth will be provided. Occasionally, I may be asked to participate in a session with the minor to assist him/her to communicate his/her progress and goals. I also understand that I will be informed of any safety concerns to the minor. I understand this authorization may be revoked, in writing, at any time. If not previously revoked, this authorization shall remain effective one year from the date of the signature below.
Parent/Legal Guardian Name*

First NameLast Name
Parent/Legal Guardian Phone Number*
Please enter a valid phone number.
Parent/Legal Guardian Email*
example@example.com
Please list the names of all those that have legal custody/guardianship of the client.*
Do you have legal paperwork that establishes custody or guardianship of the child?(If so, you will be asked to upload it.)*

No — I am the legal caregiver, and no custody paperwork exists.Yes — I have legal custody/guardianship and will upload documentation
Please upload the legal paperwork establishing custody or guardianship (e.g., custody order, DSS paperwork, guardianship documents). File Upload*

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Client Contact and Communication
Client Email*
example@example.com
Client Phone Number*
Please enter a valid phone number.
Primary Language*

EnglishSpanishOther
Communication preferences*

EmailTextPhone Call
I consent to communication by these methods.*

Yes, I consent.

Referral and Accessibility
How did you hear about us or who referred you?*
Would you like us to contact your referral source for coordination of care?*

YesNo
Referral Source Name/Organization
Referral Source Contact Information (Email, Fax, Phone)
ADA Accommodations Requested?

Reason for Services
Why you are seeking treatment?*
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

YesNo
Any current diagnosis you would like us to be aware of?*
Any current medications regularly taken?*
Are there any open DSS investigations/custody issues we need to be aware of?*

YesNo
Provider Preferences/Other Treatment Considerations
List any preferences or details you’d like us to know (for example: provider style, gender, experience with specific concerns, scheduling needs, or other factors that may affect your comfort and progress). We can’t guarantee specific matches, but we’ll do our best to accommodate your preferences whenever possible.
Are you willing to be seen via Telehealth?*

YesNoMaybe/Unsure

Insurance and ID
Will you be filing insurance?*

Yes, I will be using an insurance to pay for services.No, I will be paying out of pocket for services.
Insurance company name*
Policy Holder Name*

First NameLast Name
Policy Holder DOB*

MonthDayYear
Date
Policy Holder Relationship to Client*
Upload the front of the insurance card covering the client.*

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Upload the back of the insurance card covering the client.*

Cancelof
Do you have a secondary insurance?*

Yes, I am covered by two insurances.No, I am covered by one insurance or I will be self-pay.
Upload the front of the secondary insurance card covering the client.*

Cancelof
Upload the back of the secondary insurance card covering the client.*

Cancelof
Upload the front of your Driver’s License or State ID.*

Cancelof
Upload the back of your Driver’s License or State ID.*

Cancelof

Insurance Opt-Out Agreement
I understand and agree that:
- I have voluntarily elected not to use my insurance for counseling sessions;
- A New Leaf Therapeutic Services PLLC nor my therapist did not encourage, initiate, coerce, persuade, imply, or otherwise cause me to opt out of my insurance, verbally or otherwise; this
  decision is my own for my own reasons;
- I am not opting out of using my insurance to gain a specific time slot or any auxiliary benefits provided by my therapist, implied or otherwise;
- My treatment was not threatened in any way by either signing (or not signing) this opt out form;
- Opting out of my insurance means that I must pay out-of-pocket for the counseling sessions of the
  stated self-pay rate in the Contract and Consent Form;
- I have made my therapist aware that I am voluntarily decided to opt out of using my insurance for
  counseling sessions even if she is in-network or out-of-network;
- I will let my therapist know if anything changes, and I either obtain alternative insurance and/or decide that I would like my sessions billed to my insurance;
- If I opt of out using my insurance, I cannot use the payment of sessions towards my deductible and
  my therapist will not provide superbills for reimbursement purposes;
- I cannot opt out of services individually (i.e. I want to opt out of insurance for video sessions but not for in-person sessions) and that by opting out, I am opting out of entirely using my insurance for
  all services;
- If I elect to voluntarily use my insurance in the future, my therapist reserves the right not to allow
  me to opt out of using my insurance again;
- If I choose later to use my insurance, my therapist is not liable and is not obligated to reimburse
  previous sessions where I have chosen to opt out of billing my insurance; and
  A New Leaf Therapeutic Services PLLC
- If I choose later to use my insurance, my opting back into using insurance will start from the day I
  notify my therapist of the change and cannot be backdated to previous sessions.
- This agreement is in effect from one year of signed date until I voluntarily elect to make changesand use my insurance; I acknowledge that I have been given the opportunity to ask questions, and that A New Leaf Therapeutic
  Services PLLC has verbally explained the risks and benefits of signing the Insurance Opt Out Agreement.
If you have any questions or are unsure about this decision, please stop and contact our administrative team before acknowledging this section and signing this document.

You can reach us at 910-493-3555 during business hours (Monday–Friday, 8:30 AM – 5:30 PM EST). We’ll be happy to review your options with you.
I have read, understood, and agree to the terms contained in the Insurance Opt-Out Agreement and wish to continue as a private-pay client.*

Yes, I have read, understood, and agree.

Fees, Cancellations and Financials
Fees and Length of Treatment

I understand and agree to the following standard fees for services at A New Leaf Therapeutic Services PLLC:
- Initial Intake Appointment: $175 (Ph.D. clinicians: $250)
- 60-minute session: $100 (Ph.D. clinicians: $150)
- 45-minute session: $75
- 30-minute session: $50
If I am using insurance, my financial responsibility will instead be my copay or deductible as determined by my insurance plan.
I have read and agree to the above fees and payment terms.*

Yes, I agree.
Cancellation, Attendance, and Missed Appointment Policy
1. When you schedule an appointment, that time is reserved specifically for you. If you need to cancel or reschedule, please contact our office at 910-663-4014 at least 24 hours in advance so we can offer that time to another client.
2. Appointments cancelled or missed without 24-hour notice will be subject to a $75 missed appointment fee. If you have not arrived or joined the session within 15 minutes of the scheduled start time, the appointment will be considered a late cancellation, the session will not proceed, and the time will be forfeited.
3. However, we understand that emergencies and unexpected illnesses occur; these will be reviewed on a case-by-case basis. When applicable, any fees must be paid before or at your next appointment.
4. Some insurance plans prohibit charging for missed or late-cancelled appointments. In those cases, fees will not be applied, but repeated missed appointments will still result in closure of services. Clients with two or more missed or late-cancelled sessions without communication will be considered to have discontinued treatment.
5. Appointment reminders are provided as a courtesy only. Not receiving a reminder does not excuse a missed or late-cancelled appointment.
I have read and understand the cancellation, attendance, and missed-appointment policy above.*

Yes, I have read and understand.
Payment for Services
1. Payment is due at the time services are provided unless other arrangements have been made in advance. Please notify A New Leaf Therapeutic Services PLLC immediately if any issue arises that may affect your ability to make timely payment.
2. Accepted forms of payment include cash, credit card, or check. A $20 fee will be applied for any returned or insufficient-fund checks.
3. Clients are responsible for payment for all completed sessions and for any session missed or cancelled without at least 24-hour notice, except in cases where insurance regulations (such as Medicaid) prohibit charging missed appointment fees.
4. Even if you are currently covered by such insurance regulations, please review and sign this policy so that you are aware of expectations should your insurance coverage change during your time in treatment.
I have read and understand the payment policy above.*

Yes, I have read and understand.
Clinician Right to Discontinue Treatment

While clients may end treatment at any time, clinicians also reserve the right to discontinue services when continuation is no longer appropriate.

A clinician may end services and provide referrals to alternate providers when:
- Treatment is no longer clinically beneficial or appropriate.
- The client would be better served by another professional or level of care.
- The client has two or more unpaid sessions without an approved payment arrangement.
- The client has two or more missed or late-cancelled appointments without sufficient communication.
- The clinician determines within the first few sessions that the client’s needs fall outside the clinician’s scope or specialty.
In such cases, the clinician will discuss the reasons for termination when possible and assist with appropriate referrals to ensure continuity of care.
I understand that A New Leaf Therapeutic Services PLLC or my clinician may discontinue treatment when continuation is no longer appropriate, and that referrals will be offered if needed.*

Yes, I understand
Testimony/Clinical Work Product Fees

The fee for services for testimony and clinical work product for patient legal needs is $350.00 per hour for all tasks performed, including but not limited to analysis, calculations, conclusions, testimony, preparation ofreports, documentation and necessary travel time.
Expenses incurred by any A New Leaf Therapeutic Services PLLC staff member providing services shall be reimbursed by the client-attorney as follows: Travel by Car: .56 cents per mile (or the currently designated federal/state rate); documents shall be reimbursed for copy at .07 cents per page; and for any travel of more
than eighty (80) miles from A New Leaf Therapeutic Services PLLC clinical staff member office, any A New Leaf Therapeutic Services PLLC clinical staff member shall be reimbursed for the cost of meals and lodging. A specific, detailed contract for services regarding the above will be provided for you and your attorney should A New Leaf Therapeutic Services PLLC Staff be required to provide expert witness or related services for you.
I understand and agree to the fees associated with testimony or court-related services provided by my therapist.*

Yes, I understand
Would you like to keep a credit card on file for billing convenience? If yes, we will reach out to you to set up payment.*

YesNo
I decline to place a credit card on file with A New Leaf Therapeutic Services PLLC.I understand that it is my responsibility to make timely payments for all services received and that failure to make necessary payment arrangements may result in my scheduled appointments being cancelled and/or discharged from services.*

I acknowledge and agree to the above statement.

Emergency and Medical Consent
Emergencies

Emergencies are unexpected events that require immediate attention and may pose a threat to your health or safety.

If an emergency occurs during business hours, please clearly state “emergency” when leaving a message so your clinician or the on-call clinician can return your call as soon as possible.

If you do not receive a response within 60 minutes, or if the situation remains urgent, please call 911, contact your physician, or go to the nearest emergency department.
I have read and understand the emergency procedures described above, including what to do if I cannot reach my clinician in a crisis.*

I have read and acknowledge the emergency policy.
Limited Release of Information

By providing an emergency contact, you authorize A New Leaf Therapeutic Services PLLC to release only the minimum necessary information to that person in the event of a life-threatening medical or safety emergency.

This may include information needed to obtain emergency medical care or ensure your immediate safety.

This limited authorization does not allow disclosure of other personal, clinical, or scheduling information and cannot be used for routine communication or appointment coordination.
I have read and understand the Limited Release for Emergency Communication section above, which allows A New Leaf Therapeutic Services PLLC to share only the minimum necessary information with my listed emergency contact in a life-threatening medical or safety emergency. This authorization does not permit the disclosure of any other personal, clinical, or scheduling information.*

I understand and consent to the limited release of information described above.
Emergency Contact (Who should we contact in case of an emergency?)*

First NameLast Name
Relationship to Client*
Emergency Contact Phone Number*
Please enter a valid phone number. Please list the best number to reach them.
Do you authorize A New Leaf Therapeutic Services PLLC to make emergency medical decisions on your behalf if you are unavailable?*

YesNo
Thank you. This authorization allows your clinician or on-call staff to coordinate emergency care in the event that you cannot be reached.
You have chosen not to grant emergency medical authorization. Please provide written instructions for how you would like us to respond if we cannot reach you during a medical emergency.

Legal and Privacy Acknowledgments
Therapeutic Contract & Consent for Treatment

I understand that therapy involves participation in a professional relationship designed to help me achieve personal goals, address specific concerns, and promote overall mental health and well-being.

I recognize that therapy may include discussions of difficult emotions or experiences, and that progress may take time and effort. I agree to participate actively and communicate openly with my clinician.
I have read and understand the information above and consent to participate in treatment at A New Leaf Therapeutic Services PLLC.*

Yes, I acknowledge.
HIPAA

HIPAA Privacy Rule and Sharing Information Related to Mental Health
http://hhs.gov/ocr/privacy/hipaa/understanding/special/mhguidance.html

A New Leaf Therapeutic Services PLLC follows federal privacy laws under the Health Insurance Portability and Accountability Act (HIPAA). Your personal health information is protected and will not be shared without your written consent, except in situations required by law (such as safety concerns or court orders).

Psychotherapy notes, the private notes created by your clinician to document or analyze therapy sessions, are kept separate from your medical record. These notes are not part of your regular clinical record and are not shared with anyone, including parents or guardians, unless specifically permitted by law or with the clinician’s written approval.

Parents or guardians of minors generally have access to the child’s treatment information contained in the medical record (such as diagnosis, treatment plan, and progress updates), but not to psychotherapy notes. Clinicians will use their professional judgment to determine what information may be shared to support treatment while protecting the client’s privacy.
I acknowledge that I have reviewed and understand the HIPAA Notice of Privacy Practices.*

Yes, I acknowledge.
Telehealth Consent

I understand that telehealth involves the use of electronic communications to provide therapy services when in-person sessions are not possible or preferred.

I acknowledge that:
1. Telehealth sessions will not be recorded without my written consent.
2. I am responsible for ensuring privacy on my end during sessions.
3. I may stop telehealth sessions at any time and request in-person care when available.
4. Technology limitations or disruptions may occasionally occur.
I have read and understand the telehealth policy and consent to receive services via telehealth when applicable.*

Yes, I have read and understand the policy.
Communication Consent

I authorize A New Leaf Therapeutic Services PLLC to contact me using the methods I have provided (phone, voicemail, text, email) for appointment reminders, scheduling, or administrative purposes.

I understand that electronic communication, while convenient, may carry limited confidentiality risks. Sensitive clinical information will not be shared via text or email without my explicit permission.
I consent to receive communication from A New Leaf Therapeutic Services PLLC for scheduling and administrative purposes using my preferred contact methods.*

Yes, I consent.
Bloodborne Pathogens and Confidentiality Notice

I acknowledge that A New Leaf Therapeutic Services PLLC follows OSHA and CDC guidelines for the prevention and management of exposure to bloodborne pathogens.

In the rare event of potential exposure during treatment, I understand that confidentiality will be maintained while ensuring all required health and safety reporting standards are met.
I have read and understand the confidentiality and safety policies regarding bloodborne pathogens.*

Yes, I have read and understand.

Symptom Screener

Instructions to parent/guardian:
Below are questions about your child’s behaviors and feelings over the past month. Please choose the answer the aligns with how often each statement has been true.
My child has seemed sad, down, or hopeless.*
My child has lost interest in activities they usually enjoy.*
My child appears nervous, tense, or on edge.*
My child worries excessively or has a hard time controlling worries.*
My child has repeated thoughts that seem difficult for them to stop.*
My child feels driven to repeat certain behaviors or rituals.*
My child has nightmares, upsetting memories, or sudden reminders of past events.*
My child avoids people, places, or things that remind them of something upsetting.*
My child talks about hearing or seeing things others do not.*
My child believes others are out to harm them or control their thoughts.*
My child has had periods of being unusually energetic, excitable, or irritable.*
My child has needed little sleep or acted with racing thoughts.*
My child often argues with most adults or refuses to follow rules.*
My child has lied, stolen, or hurt others without showing guilt.*
My child has trouble focusing or finishing tasks.*
My child often loses or forgets important things.*
My child is unusually restless or has trouble sitting still.*
My child often acts before thinking or interrupts others.*
My child has used alcohol, vaping, or drugs.*
My child’s use of alcohol, vaping, or drugs has caused problems at home, school, or with friends.*
Function / Impact Section

How much have your child’s symptoms affected these areas of life in the past month?
School performance*
Relationships with family*
Relationships with friends/peers*
Daily responsibilities (chores, hygiene, following routines)*
Overall happiness and quality of life*

Symptom Screener

Instructions:
Below are questions about how you’ve been feeling or acting recently. Please circle how often each statement has been true for you over the past month.
I have felt sad, down, or hopeless.*
I have lost interest or pleasure in things I usually enjoy.*
I have felt nervous, anxious, or on edge.*
I have worried excessively or found it hard to control my worry.*
I have repeated thoughts or images that are hard to get rid of.*
I feel driven to repeat certain behaviors or rituals to reduce anxiety.*
I have unwanted memories, nightmares, or flashbacks about past events.*
I avoid people, places, or things that remind me of something upsetting.*
I have heard or seen things that others could not.*
I have felt that others were watching me, plotting against me, or controlling me.*
I have had periods where I felt unusually high, energetic, or irritable.*
During these times, I needed little sleep or felt my thoughts were racing.*
Before I turned 18, I often argued with adults or refused to follow rules.*
Before I turned 18, I lied, stole, or hurt others without feeling guilty.*
I have difficulty sustaining attention or completing tasks.*
I often lose or forget important things.*
I feel restless or have trouble sitting still.*
I often act before thinking or interrupt others.*
I use alcohol or drugs more than I mean to.*
I have tried to cut down on alcohol or drugs but couldn’t.*
My use of alcohol or drugs has interfered with my work, school, or relationships.*
Function / Impact Section

How much have your symptoms affected these areas of your life in the past month?
Work or school performance*
Relationships with family or friends*
Daily responsibilities (e.g., household tasks, self-care)*
Enjoyment of life / overall well-being*

Signature Page
By signing below, I First Name* Last Name* acknowledge I have reviewed and agree to the above consents and policies. My signature below serves as confirmation and proof of my agreement to these terms.
Signature*

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Counseling Intake Form

Patient Information

Parent/Guardian Information

Client Contact and Communication

Referral and Accessibility

Reason for Services

Insurance and ID

Insurance Opt-Out Agreement

Fees, Cancellations and Financials

Emergency and Medical Consent

Legal and Privacy Acknowledgments

Release of Information

Signature Page