New Client Registration

New Client Registration

Welcome to Sage Minds Mental Health Counseling!
Please provide the following information before getting started with your therapist. We look forward to working with you!
Name*

Legal First NameLegal Last Name
If you prefer to go by another name, please write below:
Date of birth:*

MonthDayYear
Date
Gender:*
Race/Ethnicity:*
Preferred email address:*
example@example.com
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred phone number:*
Please enter a valid phone number.
Are you comfortable with your therapist texting the above number:*

YesNo
Emergency Contact Name:*
Relationship to Emergency Contact:*
Emergency Contact Phone Number:*
Please enter a valid phone number.

Marital Status:*
Children:*
Highest Level of Education:*
Are you currently employed?*

Yes, full-timeYes, part-timeNo
Current Occupation:*
If unemployed, please write most recent position and when you left
Employer Name:*
If unemployed, please write N/A

Mental Health History:
Reason(s) for starting psychotherapy at this time:*
Primary Care Physician Name and Phone Number:*
Psychiatrist Name & Phone Number:*
if none, write N/A
If currently or previously prescribed psychotropic medication (antidepressants, anti-anxiety meds, etc), please names, dosage, and dates of use below: *
if none, write N/A
Previous therapists names & phone numbers:*
if none, write N/A
If you've previously received psychotherapy, please write dates in treatment and reason(s) for treatment:*
if none, write N/A
Previous hospitalizations for mental health treatment:*
dates, length of treatment, hospital name
Please describe any other form of mental health care you are receiving or have received in the past:*
i.e. group therapy, retreats, etc
Please describe any developmental delays you've experienced or development-related diagnoses you've received:*
i.e. group therapy, retreats, etc
Please describe any special circumstances that are negatively impacting your stress or mental health:*
medical conditions, illnesses, deaths of loved ones, separations, relocations, etc
Has anyone in your family ever experienced mental health or substance abuse issues?*
Please list relationship and a brief description of their issue(s)
Has your physical health been negatively impacted by your mental health symptoms? If yes, please explain.*
Has your career been impacted by your mental health symptoms? If yes, how so?*
Have your interpersonal relationships been impacted by your mental health symptoms? If yes, please explain.*
Please describe your relationship(s) with your family.*
Describe your social activities and non-familial relationships.*
Please use the below space to describe any other aspects of your life that have been impacted by your mental health symptoms.

If yes, please describe:*
If no, type N/A
What spiritual practices and cultural traditions are important to you?*
What strengths and abilities are you bringing to sessions?*
What are you looking to learn and/or gain from your sessions? *
Anything else you feel is important for your therapist to know about you?*

Insurance Information

Please provide your insurance information below:
Primary Insurance Co:*
Primary Insurance Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance ID #:*
Policy Holder's Name:*

First NameLast Name
Policy Holder's DOB:*

MonthDayYear
Date
Policy Holder's Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder's Phone Number:*
Please enter a valid phone number.
Please upload a photo of the front of your primary insurance card:*

Cancelof
Please upload a photo of the back of your primary insurance card:*

Cancelof
Secondary Insurance Co:
Secondary Insurance Co Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance ID #:
Policy Holder's DOB:

MonthDayYear
Date
Policy Holder's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Holder's Phone Number:
Please enter a valid phone number.
Please upload a photo of the front of your secondary insurance card:

Cancelof
Please upload a photo of the back of your secondary insurance card:

Cancelof
Who is responsible for this bill?*
I certify that this information is true and correct to the best of my knowledge. I understand the above statements and I will notify Sage Minds Mental Health Counseling of any changes in my health insurance status. If I do not notify the practice of any changes and my insurance does not cover any services rendered, I will be responsible for any outstanding balance(s).
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Practice Policies and Consent
Welcome to Sage Minds Mental Health Counseling, PLLC!

Please read the following carefully as it provides important information. Over time, we have found that clarity in regard to professional and business policy is essential in establishing a strong and trusting therapeutic relationship. If you need to reference back to these policies, a copy can be found on our website. The therapist/client relationship is unique. So that therapy may be most beneficial, it is important that both therapist and client have a clear understanding of the responsibilities and commitments involved. Your therapist will be happy to go over any questions you may have.

RIGHTS/EXPECTATIONS OF CLIENT:
The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the New York State Department of Regulatory Agencies. Any questions, concerns, or complaints regarding the practice of mental health counseling may be directed to:

State Board of Social Workers, Marriage and Family Therapists and Professional Counselors P.O. Box 2649 Harrisburg, PA 17105-2649 (717-783-1389).

You are entitled to receive information about methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure. You may seek a second opinion from another therapist or terminate therapy at any time. You should know that in a professional relationship, sexual intimacy is never appropriate and should be reported to the Grievance Board.

Psychotherapy can help you transform limiting beliefs, reduce the frequency of uncomfortable feelings, access your strengths, enhance your self-awareness, improve your relationships, and move toward a sense of wholeness and improved overall functioning. Progress and length of therapy vary from person to person, depending on a variety of factors including the nature and intensity of the presenting problems, the goals of treatment, motivation, and any life circumstances that may arise over the course of therapy. While most people benefit from psychotherapy, the process can be difficult at times and trigger some uncomfortable feelings. These feelings are a natural part of the healing process and can be a catalyst for change.

CONFIDENTIALITY:
You should understand that information provided by a client during therapy is legally confidential and cannot be disclosed without the client’s written consent. Occasionally your therapist may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Your therapist may share information about you in this context without using your name or any other identifying information. Overall, all communications and your presence here will be held as confidential except when you provide your therapist with written permission to disclose specific information on your behalf or when the following circumstances apply:
- According to New York and federal law, your therapist may need to break confidentiality to exercise their duty as a mandated reporter of suspected child abuse, elder abuse, and dependent adult abuse. (This includes physical, emotional or sexual abuse and/or severe neglect).
- If you present a serious threat of harming yourself or are gravely disabled (unable to provide food, shelter, or clothing for yourself), your therapist may need to break confidence to protect you.
- If you present a believable threat to harm another person or to property, your therapist is required by law to warn that person of the possible danger, and to notify the police.
- If your records are subpoenaed by a legitimate court order, your therapist may be required to provide them.
Your therapist will discuss with you any other exceptions of confidentiality should the need arise. If you happen to see your therapist outside of the therapy space, your therapist will not acknowledge you first due to your right to privacy and confidentiality being of the utmost importance to us. Please discuss any preferences you may have for potential encounters with your therapist.

Please note, if you are involved in divorce or custody litigation, the role of your therapist is NOT to make recommendations to the court regarding custody or parenting issues. By signing this disclosure statement, you agree NOT to subpoena your therapist to testify or disclose treatment information. Furthermore, you agree NOT to request that your therapist write any reports to the court or your attorney regarding custody and parenting issues. The court can appoint professionals, who have no prior relationship with family members, to conduct an evaluation or investigation concerning such matters.

MINORS:
If you are a minor, your parents may be legally entitled to some information about your therapy. Your therapist will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

FEE SCHEDULE/INSURANCE:
The amount of your fee for psychotherapy will be established at the beginning of your therapy. We typically increase our fees approximately $15 each year depending on multiple variables. Your therapist will announce any increase in fee at least one month in advance. If your fee has been adjusted due to financial limitations, you agree to report any changes in your financial situation so that fees can be readjusted accordingly. Fees are due at the beginning of each session.

If you are planning to utilize your insurance benefits to cover the cost of your sessions, please be aware that it is your responsibility to be up-to-date on your coverage, any deductible/copays/co-insurance costs, and any potential limitations of coverage. Please be aware that should your insurance decline to pay for the services received, you will be responsible for the cost of the services. If you are using out-of-network benefits, we can provide the information necessary for reimbursement.

CANCELLATIONS:
Our goal is to provide quality counseling services to all of our clients in a timely manner. No-shows, late arrivals, and late cancellations inconvenience not only our providers, but our other clients as well. Please be aware of our policy regarding missed appointments.

When you book your session, you are holding a space in your therapist’s calendar that is no longer available for our other clients. In order to be respectful of our fellow clients, please contact your therapist as soon as you know you will not be able to make your session. It is expected that if an appointment needs to be canceled, as much advance notice as possible will be given so that the time can be offered to fellow clients. A fee of $85 will be made for sessions canceled less than 48 hours in advance. (Please note that insurance will not reimburse for missed sessions, even if advance notice is given).

TERMINATION:
Termination ideally occurs when a client has met their treatment goals and will no longer benefit from therapy. However, please know that treatment may be terminated at any time, but three final sessions are recommended in order to bring closure to the work. If your therapist chooses to terminate treatment, they are responsible for informing you and will provide you with appropriate notice and necessary termination sessions to ensure as much closure as possible.

LENGTH OF SESSIONS:
All psychotherapy sessions are between 45 and 50 minutes in length with time beginning at the scheduled start time. Your therapist will discuss the length of your sessions with you when treatment begins. We do not charge for brief phone conversations between sessions lasting less than 15 minutes. Should you need a longer check in, your therapist will discuss the rate with you prior to the conversation.

EMERGENCY PROCEDURES:
Due to work schedules, your therapist is often not immediately available. When they are unavailable, you should leave a voicemail requesting a return call and they will make every effort to return your call within one-two business day(s). If you are experiencing a life-threatening emergency or crisis you should call 911 or go to the nearest Emergency Room.

Your signature below indicates that you have read and agree to the above policies and procedures.

We look forward to working with you!
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Consent for Teletherapy
This Informed Consent for Teletherapy contains important information focusing on doing psychotherapy using the phone or the Internet. The benefits and risks of teletherapy refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of teletherapy is that the client and clinician can engage in services without being in the same physical location, whether it be due to physical or mental disability, or temporarypermanent location change. Even if you are choosing to currently solely engage in in-person sessions, this consent will be necessary should the need for a teletherapy session ever arise.

Risks to confidentiality:
Your therapist will engage in teletherapy only in a secure location allowing for no visual or auditory information to be seen or overheard by others. It is important for you to make sure you find a private place for our session where you will not be interrupted or overheard or distracted.

Issues related to technology:
There are many ways that technology issues might impact teletherapy. For example, technology may stop working during a session. It is a legal requirement as a professional in the field of psychotherapy that a HIPAA compliant platform for communication that prevents any others from listening to the session material. Not all platforms have such compliance.

Crisis management and intervention:
Teletherapy with clients who are currently in a crisis situation requiring high levels of support and intervention are generally not considered good candidates for such a medium. Should a crisis situation develop, it is necessary that an emergency contact person, who preferably is near your location. This will require a separate form with contact information.

Efficacy:
Most research shows that teletherapy is about as effective as in-person psychotherapy, however some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.

Electronic Communications:
Computer or mobile phone with an optical device is used for teletherapy. Confidentiality of any information communicated by email or text or phone cannot be guaranteed. If an urgent issue arises, the undersigned clinician can be reached by phone. If,under unlikely circumstances, you cannot reach me, you should contact the nearest emergency room or call 911.
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Should be Empty:

	Not at all	Several Days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Moving to speaking so slowly that other people have noticed OR the opposite, being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or hurting yourself

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

New Client Registration

Insurance Information

PHQ-9

GAD-7

Practice Policies and Consent

Consent for Teletherapy