Intake Form

Intake Form
Client Name
Date

MonthDayYear
Date
Preferred Name
Preferred Pronouns
Date of Birth

MonthDayYear
Date
Age
Relationship status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
City, State, Zip

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact (Name + Phone #)
Client Email
example@example.com
Is it acceptable to communicate via email?

YESNO
Client Phone #
Is it acceptable to leave a voicemail/text?

YESNO
Would you like to add your email to the INUR WELLNESS never-monthly email list?

YESNO
Other Email/Phone #
Relationship to Client
Is it acceptable to leave an email/voicemail/text?

YESNO
How did you hear about Tara Herrick Brown, M.S.?
Referred by:
*Relevant Medication(s):
What is the reason(s) for your visit today?
Primary concerns, in order of importance:
1.
2.
3.
* For informational purposes only. Tara Herrick Brown, M.S. does not prescribe or make recommendations regarding medications.

PRACTITIONER-CLIENT SERVICE AGREEMENT
Thank you for choosing INUR Wellness, LLC for your counseling needs. This document contains important information about the professional services and business policies of the practices of Tara Herrick Brown, M.S. and INUR Wellness, LLC.
I. COUNSELING SERVICES
Counseling sessions can vary from weekly-to-monthly check-in meetings. Typically, the initial period are meetings held for two-to-four consecutive weekly sessions. During this time, possible recommendations and whether the therapeutic relationship is a good fit for both parties is determined. If needed, appropriate referrals can be made during the initial evaluation period.
II. CLIENT ADVISORY
Tara Herrick Brown, M.S. is committed to your health and wellbeing. Although she has a master's degree in psychology and has been offering holistic counseling for 18 years, she cannot replace the resources available through medical physicians and psychiatric experts. If appropriate, Tara may recommend that you consult a naturopathic or allopathic physician or licensed psychiatric professional pertaining to the reason(s) for which you seek counseling services.
III a. CONFIDENTIALITY
Counseling is the most effective when built upon a trusting relationship between the practitioner and client. Privacy is especially important in securing and maintaining trust. The information provided will be treated confidentially and will not be made available to any third party without your written consent.
For couples, it is common for each partner to attend sessions independently. The purpose of the individual sessions is to better the partnership and therefore, Tara will encourage most information shared in individual sessions to be shared in the couple setting. If there is a topic that an individual asks to remain confidential, Tara will use her best judgment as to if/when/how the information is shared with the partner, but only in the presence of the other and always with prior notice.
The instances in which confidential information can or must be released without consent is stated below:
- If you pose a serious danger to yourself or others.
- If you neglect or abuse a child or adult, or if abuse or neglect is suspected.
- If there is a child-protective services (CPS) investigation.
- If a court issues a subpoena concerning your records.
In cases where information must be released without consent, every attempt will be made to notify you beforehand.
III b. CONFIDENTIALITY (for minors)
Counseling is the most effective when built upon a trusting relationship between the practitioner and client. Privacy is especially important in securing and maintaining trust. One goal of counseling is to promote a stronger and better relationship between adolescents and their parents. However, it is often necessary for children to develop a "zone of privacy" where they feel free to discuss personal matters. This is particularly true for adolescents who naturally are developing a greater sense of independence and autonomy.
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By signing this agreement, you are waiving your rights to access Tara's session notes regarding your child. It is her policy to provide you with general information. She will raise issues that may impact your child either inside or outside the home. You are welcome to contact her with information you deem pertinent to your child's physical, mental, emotional, and spiritual health and wellbeing. She will take all information into consideration and may choose to share the information you send to her with your child during our session(s).
Tara will not share with you what your child has disclosed in their sessions without their consent. If your child is an adolescent, it is possible they will reveal sensitive information regarding sexual contact, alcohol or drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. If Tara ever believes that your child is at serious risk of harming themselves, she will inform you.
IV. FEES & OFFICE POLICIES
Office Hours: The office is open by appointment only.
Insurance Billing: Tara Herrick Brown, M.S. does not accept insurance for payment.
Appointments and Fees: Visits last 55-60 minutes and cost $175.
A rate of $25 for each additional 15 minutes will be added to sessions lasting longer than the scheduled duration.
Payment is due at the time of service. Tara accepts cash, checks and all major credit cards. There is a $25 fee for all returned checks.
If any payment is overdue by more than seven (7) days, a credit card will need to be provided, to be kept on file, before any future appointments are scheduled.
Virtual Sessions: Telephone or Zoom appointments are available. Fees for virtual sessions are set at the same rate as in-person visits. Brief phone calls are accepted at no charge. Messages are checked daily and will be returned within 24-48 hours.
Email Policy: If you need clarification about issues that arose in a previous session or if you need to change or make an appointment, this may be done by email.
Appointment Cancellations: It is inevitable that circumstances occasionally arise that will change your plans. You may cancel your scheduled appointment at no charge if you cancel at least 24 hours before your appointment. Cancellations are accepted using the online booking system or by contacting Tara directly via telephone, voicemail, email, or text.
If you do not cancel with a 24-hour notice or fail to show for your appointment, you will be charged a $100 cancellation fee. Cancellations due to illness may be waived on a case-by-case basis.
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IV. INFORMED CONSENT
I understand that Tara Herrick Brown, M.S. offers holistic counseling services (offering advice, support, and encouragement) and is not a licensed mental health counselor.
Most of my work with Tara Herrick Brown, M.S. will be conversation. At times, she may offer modalities including, but not limited to the use of homeopathy, essential oils, and flower essences. I understand that these offerings are optional, and I may decline.
I do not expect Tara Herrick Brown, M.S. to be able to anticipate and explain all possible risks or benefits of our work together. Sometimes, things are uncovered during counseling that can have unanticipated emotional effects. I wish to rely on her to exercise judgment while working together which she thinks, at the time and based upon experience and the facts known to her, is in my best interest.
I consent to counseling services with Tara Herrick Brown, M.S. I read and understand these guidelines and agree to the terms therein and have been given an opportunity to ask questions and discuss concerns related to the terms with Tara Herrick Brown, M.S.
By voluntarily signing below I show that I have read this consent in its entirety. I intend this consent form to cover the duration of my/my child's work with Tara Herrick Brown, M.S.
Client's Signature (or representative, if client is a minor)
Date

MonthDayYear
Date
TARA HERRICK BROWN, M.S.
Date

MonthDayYear
Date
Tara Herrick Brown, m.s.

holistic counseling
www.inur.com · tara@inur.com · 518.703.7335

INUR Wellness, LLC
10 McKown Rd, Ste 200
Albany, NY 12203
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Should be Empty:

Intake Form

Primary concerns, in order of importance:

PRACTITIONER-CLIENT SERVICE AGREEMENT

I. COUNSELING SERVICES

II. CLIENT ADVISORY

III a. CONFIDENTIALITY

III b. CONFIDENTIALITY (for minors)

IV. FEES & OFFICE POLICIES

IV. INFORMED CONSENT