• INTAKE FACE SHEET

  • CLIENT INFORMATION

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Please enter a valid phone number.
  • Format: (000) 000-0000.
  • Please enter a valid phone number.
  • Format: (000) 000-0000.
  • Please enter a valid phone number.
  • example@example.com
  • Employment Status*
  • Marital Status:*
  • Gender:*
  • Student Status:*
  • Race*
  • Need Interpreter*
  • Have you previously received or currently receiving mental health services?*
  • Format: (000) 000-0000.
  • Please enter a valid phone number.

  • PARENT/GUARDIAN INFORMATION

  • Emergency Contact Information

  • Format: (000) 000-0000.
  • Please enter a valid phone number.

  • Client Data Form

  • Presenting Problems*
  • If suicidal, homicidal, gravely impaired or need further clinical guidance contact a licensed clinician to further assess for triage! Document clinical disposition when applicable

  • MEDICAL HISTORY Questionnaire

  • Are you taking any medications (prescription, over the counter vitamins, homeopathic or naturopathic remedies, traditional or alternative medicine remedies, herbs)?*
  • Are you allergic to any medications?*
  • Do you have any other allergies?*
  • Are you currently pregnant?*
  • Are there any medical problems that you are currently receiving treatment for?*
  • Identify the medications that you are currently taking for medical or behavioral health concerns, and the reason for take the medications, below:
  • Rows
  • Does your current medical condition(s) create problems in how you deal with life, including pain?*
  • Date*
     - -

  • CONSENT FOR TREATMENT

  • 1. I consent to and authorize treatment through ThriveWell Counseling Solutions LLC.
    2. I authorize the collection of necessary administrative dates regarding me. I understand that such data shall be computerized for statistical, programming, and billing purposes.
    3. I understand information regarding me shall be collect responsibility and maintained in a confidential clinical record. Any such records or information shall remain confidential except in the following incidences:
    a. Information required by third party payers and parties giving CSC authorization to provide said services shall be forwarded to them.
    b. Records shall be open to ThriveWell Counseling Solutions LLC staff as needed and to appropriate state mental health officials.
    c. Information may be exchanged if I sign a written release form indicating the nature of information to be released.
    d. Information, which indicates a severe threat to the life or safety or another person or to self, shall be forwarded to the threatened parties or appropriate agencies to the extent necessary to protect life and safety.
    e. Information will be released if required under a court subpoena.
    f. Suspected abuse or neglect shall be reported to Protective Services as mandated by the Code of Federal Law.
    g. State and Federal law prohibits the disclosure of any information identifying a Recipient as receiving alcohol/drug services unless the Recipient consents in writing, the disclosure is allowed by court order, disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluations.
    h. Federal Law does not protect any information about a crime committed by a Recipient either at the program or against any person who works for the program or about any threat to commit such a crime
    4. I understand that all services will be provided regardless of gender, color, national origin, sexual orientation, religious preference, and a level of disability.
    5. If there is a medical or psychiatric emergency, I give permission for staff to seek emergency care on my behalf.
    6. ThriveWell Counseling Solutions LLC staff may share information with my consent with other associated facilities such as group homes, Dept. of Social Services, Court Services, and Area Programs if a Recipient is seen in two or more of these agencies.
    7. I agree to satisfy my financial obligation with ThriveWell Counseling Solutions. I understand payment is due at the time services are rendered unless payment arrangements are made.
    8. You have the right to accept or refuse any medication, procedure test or treatment. Exception to this right is when there is an emergency, court order or if the recipient is under 18 years old and his/her parent or guardian has given permission.

  • I understand that I will be receiving the following services provided by ThriveWell Counseling Solutions: *
    Assessment/ Reassessment
    Skills Development and Training
    Individual /Family Intervention Counseling
    Medication Training and Support

  • Intensive Case Management
  • Group
  • Date*
     - -

  • INFORMED CONSENT FOR TELE-SERVICES

  • Tele-services involve the use of electronic communications to enable health care providers at to provide services to the client for the purpose of improving client care. The information may be used for diagnosis, therapy, follow-up and/or education. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

  • Expected Benefits:

  • More efficient evaluation and management.

  • Possible Risks:

  • In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.

  • By signing this form, I understand the following:

  • 1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
  • 2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
  • 3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.

  • Consent To The Use of Telemedicine

  • I have read and understand the information provided and all of my questions have been answered to my satisfaction. I give my informed consent for the use of tele-services in my care.
  • Date*
     - -
  • 8
  • Day Year

  • Medication Therapy Management Consent Form

  • Month

  • I have elected to make use of the medication therapy management services provided by ThriveWell Counseling Solutions. My participation is voluntary. I understand that these services are not a direct substitute for medical care provided by my physician or any other provider.

  • I understand that this consent is revocable upon written notice **

  • I authorize ThriveWell Counseling Solutions to maintain a copy of my health profile and medication related recommendations for the purpose of follow-up and monitoring. I understand that every effort will be made to maintain the confidential nature of my private health information. Information about this review will not be shared with anyone except my legal representative without my written consent.

  • Date *
  • Should be Empty: