FGWC Intake Form

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Birth Date*

MonthDayYear

Marital Status

Employer

Occupation

Spouse's Name

Spouse's Occupation

Spouse's Employer

Number of Children

Children's genders and ages

Emergency Contact*

Emergency Contact Phone Number*

Primary Care Physician

Primary Care Physician's Phone Number

How were you referred to us?

Are you experiencing any of the following symptoms at this time? (Please check all that apply)*

General Anxiety/Panic/OCD/PTSD/Social AnxietyWomen's Health Issues: Peri/Post Menopause/Fertility Issues/Sexual Disorders/Pelvic Pain/Weight and Digestion IssuesDepression/TraumaInterpersonal Conflicts, Transitioning to Divorce/SeparationIssues with Addiction: Alcohol, Drugs, Gambling, Porn, Shopping, Internet and Gaming, etcDisordered eating and elimination issuesEnvironmental issues: Work, Discrimination, Gender, Race, Ethnicity,Chronic Pain or Ongoing Medical ProblemsProcrastination and Unwanted Habits

Have you been treated for any of the above conditions in the last year?*

YesNo

List all other major illnesses or hospitalizations:

What medications or drugs are you taking?

Purpose of this appointment:*

Father

LivingDeceased

Father's current age or age at time of death and cause of death:*

Mother

LivingDeceased

Mother's current age or age at time of death and cause of death:*

What is your Birth Order

Do you have any family members who suffer from the conditions that you do? If so, please list:*

Patient's Name

If patient is a minor, parent/guardian's name

Enter the message as it's shown*

Signature*

Date*

MonthDayYear

Confidentiality statement:

Our professional ethics prevent us from telling anyone else what you tell us unless you give us written permission. There are some exceptions to this rule, where we have to break confidentiality or put limits on it. The following outline those exceptions:

A: When you or other persons are in physical and/or psychological danger, the law requires us to tell others about it to help protect.

B: In any of the following situations, we would reveal only the information that is needed to protect you or the other person. We would not tell everything you have told us.

1. In general, if you become involved in a court case or proceeding, you can prevent us from testifying in court about what you have told us. This is called “privilege,” and it is your choice to prevent us from testifying or to allow us to do so. However, there are some situations where a judge or court may require us to testify:

a) In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt.

b) In cases where your emotional or mental condition is important information for a court’s decision.

c) During a malpractice case or an investigation of us.

d)In a civil commitment hearing to decide if you will be admitted to or continued in a psychiatric hospital.

e) When you are seeing us for court-ordered evaluations or treatment. In this case, we need to discuss confidentiality fully, because you don’t have to tell us what you don’t want the court to find out through our report.

f) If you were sent to us for an evaluation by worker’s compensation or state/provincial covered disability, we will be sending our report to a representative of that agency and it can contain anything that you tell us.

Put your initials here

Parent or Guardian Initials if patient is under 18

Consent to Use and Disclose Your Health Information

When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls “protected health information” or (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, or to help provide other treatments to you.

I am aware that an agent of my insurance company or other third-party payers may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive.

By signing this form, you are agreeing to let us use your PHI and to send it to others for the purposes described above.

In order to optimize your care, from time to time we seek consultations with other licensed mental health professionals who are in the role of an expert in the matter that we seek consultation. When we do this, we eliminate all demographic and identifiable factors in order to maintain confidentiality and would limit the consultation to the specific issue we are consulting about. If you are being treated by more than one clinician in our practice, your care might be discussed amongst those clinicians in order to optimize your care.

If you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do agree, we do as you asked. After you have signed this consent, you have the right to revoke it in writing. We will then stop using or sharing your PHI, but we may already have used or shared some of it, and we cannot change that.

Put your initials here

Parent or Guardian Initials if patient is under 18

Consent to Treatment

I do hereby seek and consent to take part in psychotherapy treatments. I understand that developing a treatment plan with my treating psychologist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of psychotherapy treatment as this is the nature of this type of treatment.

I am aware that I may stop my treatment at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I understand that my services do not extend to child custody cases. We do not and will not make any child custody recommendations when treating a minor who is involved in a custody conflict. Parents and guardians who agree to engage our services for their minor contract that as the treating psychologist, we will not be called to testify or have records subpoenaed for any and all matters related to custody conflicts. If there is any initial report made to Child Protective Services, parents and guardians agree to sign for release of such report to us and for us to have follow-up contact with Child Protective Services. Likewise, we do not and will not agree to make any psychological evaluations, provide clinical services, or serve in any other ways for the purposes of fulfilling a court-ordered, mandated, or otherwise legally required clinical task.

Put your initials here

Parent or Guardian Initials if patient is under 18

Financial Agreement

PLEASE READ THE FOLLOWING AGREEMENT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE BRING THEM UP PRIOR TO YOUR FIRST SESSION BY PHONE OR EMAIL. BY SIGNING THIS FORM, YOU ARE AGREEING TO THE TERMS OF FINANCIAL RESPONSIBILITY ASKED OF YOU IN ORDER TO BECOME A PATIENT AT OUR CENTER.

Services include but are not limited to psychotherapy, psychological testing, and evaluations, consultation with others about your care, reading supporting documents about your care and preparing documents for your care.

No services will be done without your prior agreement.

Unless otherwise indicated, you are responsible for making payments for the services you receive either prior to, or at the time of service. Virtual payments are available through several platforms, and you will be informed of which platform to use prior to your appointment. In-Person services are payable at the clinic.

All appointment cancellations or changes must be made within 48 hours (2 work days) prior to the appointed time. All late cancellations and appointment no-shows will be charged at the full rate. All cancellation notices must be made either by a phone call or email to the office.

Should you choose to discontinue services before reaching your therapy goals, you are responsible for clearing payments for all the services you have received up to that point, there are no refunds for services rendered. You are not responsible for paying for any future appointments, should you cancel them within 48 hours (2 work days) prior to the appointed time.

Most therapy sessions are at the standard length of 50 minutes. However, frequently it becomes clinically beneficial to sign up for a double session, which lasts 100 minutes (1 hour and 40 minutes). All double sessions will be offered with your prior agreement. The fee for double sessions is charged at the same hourly rate times the number of sessions.

Put your initials here

Parent or guardian initials if patient is under 18

Your signature below means you have carefully read, understood and agree with all the statements above. Parent or guardian signature bellow if patient is under 18.

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