Intake Form

Intake Form
We know your time is valuable, so we appreciate your taking the time to complete this intake form. It may seem lengthy, but our therapists will find it helpful for your treatment. Additionally, some information are required by the State and your insurance company. We appreciate your time.

WRITE N/A WHERE NOT APPLICABLE
Personal Information
Name as Registered with Insurance *

First Name Last Name
Preferred Name

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date *

Month Day Year
Gender *
E-mail *
Marital Status
Emergency Contact
Emergency Contact Phone Number
Primary Care Physician
Primary Care Physician or Clinic's Phone Number
How did you hear about us? *
Please tell us which school. *
Name of school
Please specify how you heard about us. *

Present Problem
Purpose of this appointment: *
Have you ever had the same or a similar problem? *

Yes No
If yes, please describe:

Social Information
Do you do any of the following? (Please check all that apply) *

Exercise Use tobacco products Consume caffeine Sleep well at night Drink alcohol Take vitamin supplements
If you checked any of the options above, please detail below:
What are your hobbies?
What is your ethnicity?
What is your religion if applicable? *
Are you or have you been involved in any legal matters? *

Yes No
If yes, please explain. Include dates.
What is your highest level of education? *
What is your profession/occupation? *
How long have you been in this profession/occupation?

Wellness Survey
Over the last two weeks, how often have you been bothered by any of the following problems?
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 - that you are a failure or have let yourself or your family down? *
Trouble concentrating on things, such as reading or streaming videos? *
Moving or speaking so slowly that other people could 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 of hurting yourself in some way? *

Informed Consent & Confidentiality Policy
The Therapy Process

Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. If you have a crisis situation develop after hours, call the suicide prevention hotline at (877) 943-2052 or go to your local emergency room.

The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require ethical and legal commitment to the confidentiality of your Personal Health Information.

Informed Consent & Confidentiality Policy
Legal Responsibility

Under the laws of the United States and the State of Massachusetts your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.

Informed Consent & Confidentiality Policy
Use and Disclosure of Your Personal Health Information (PHI)

Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

· Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you.

· Payment - Your PHI may be used and disclosed to your health insurance plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required.

· Health Care Operations - Your PHI may be used and disclosed to staff members for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status.

· As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.

· Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.

· Appointment Reminders - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine.

· Therapist Cancellation – If for some reason an appointment must be cancelled, you will be contacted by phone or email. If contact is by phone, a recorded message may be left on your answering machine/voicemail.

· Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.

· Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.

Informed Consent & Confidentiality Policy
Patient Rights

· With limited exceptions, you can make a written request to inspect your PHI that is maintained by us for our use. Your PHI includes basic information about your diagnosis, treatment dates, treatment plans, intake and termination summaries. Psychotherapy notes may be exempt from this ruling.

· Requested copies of any PHI information will be provided at the cost of $.25 per page.

· You must make a written request to have your PHI communicated with you by alternative means at an alternative location. (An example would be if your primary language is not spoken and a child for whom you have lawful custody is being treated.) Your written request must specify the alternative means and location.

· You can make a written request that restrictions be placed on other ways we use or disclose your health information. Any or all of your requested restrictions may be denied. If these restrictions are agreed to, they will be abided by in all situations except those in which professional judgment constitutes an emergency.

· You can make a written request that your PHI be amended. If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing. If denied, you can place a written statement in your records disagreeing with the denial of your request.

Informed Consent & Confidentiality Policy
For Questions, Concerns, and Complaints

We are committed to practice according to the ethics of our profession. You may contact the Massachusetts Division of Professional Licensure and/or the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

Agreement and Understanding
Appointment Confirmations: I understand that I may be contacted via text or phone 24-48 hours in advance to confirm a scheduled appointment.
Your insurance company may require us to consult with a client’s primary care physician or psychiatrist whenever symptoms of a mental health diagnosis are present. The purpose of such consultation is to determine if there may be a medical condition or medication that may be causing or contributing to the client’s symptoms. The client/parent/legal guardian may also choose to waive such consultation. The clinician may provide treatment or evaluation until such time that the medical consultation is obtained or waived.
Notice of Privacy Practices *

I understand that I may download a copy of Notice of Privacy Practices at TCAcounseling.com/Forms.
Please check. *

At this time, I waive the consultation with my primary care or psychiatrist, understanding that I may at anytime complete a release of information to the physician of my choice.

Financial Agreement
How I plan to pay for therapy: *

I plan to use my insurance. I want to pay for my therapy (Private Pay).
Insurance Company's Name *
Member's ID Number *
Upload Front of Insurance Card

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Cancel of
Cancellation and Excessive Absenteeism Policy *

I understand that a twenty-four hour notice is required for the cancellation or rescheduling of an appointment. Appointments changed with less than 24 hour notice will incur a $55 charge, which will be applied to my credit card as insurance cannot be billed. I also understand that my treatment may be terminated if I miss more than 2 scheduled appointments in any given 4 week period.
Service Costs *

If I am not a private pay client, I understand that TCA Counseling Group will attempt to bill my insurance company, but if for any reason the service is not covered, I will be responsible for payment of that service at the rate of $150 for the first visit and $135 for each subsequent visit. I understand I will pay the amount due, including copayments and deductibles, before the session on the day of my scheduled appointment. I also understand that if I do not adhere to this agreement, services maybe suspended. If I'm a private pay client, I understand the cost for services is $150 for the first session and $135 for each additional visit.

Financial Agreement
A credit card is required to hold your appointment time. The card will not be charged unless you have a deductible, copayment, cancellation/late reschedule fee, or balances not paid by your insurance. For private pay clients, the rate of $150 will be charged for the first visit, and $135 for each subsequent visit.

Please provide us or therapist your card during your first visit so they may make a copy for your file.

If you would like us to use your HSA/FSA card, we would still need a valid credit card on file.
Credit Card Authorization *

I agree to allow TCA Counseling Group to automatically debit my credit or debit card for any costs for services not paid by my insurance, including counseling fees, co-payments,cancellation fees and no-show fees. I understand that TCA Counseling Group's primary mode of payment is cash. If I would like to have my card on-file automatically charged, there is a convenience fee of 3.8%. To process these transactions in advanced of my visits, my card information will be stored on SQUARE Payment App.
Please upload your credit card information below. If you are unable to do so, please call our office Monday - Friday between 10 am and 6 pm.
Upload Front of Credit Card

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Cancel of
Upload Back of Credit Card

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Cancel of

Signature
Please type and sign your name below to indicate consent to treatment and acknowledgement of Informed Consent, Privacy Policy and financial agreement.
Patient's Name *
Today's Date *

Month Day Year
Date
Patient's Signature *

Clear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Guardian's Name
Date

Month Day Year
Guardian's Signature

Clear
Should be Empty:

Intake Form

Personal Information

Present Problem

Medical and Mental Health Information

Social Information

Family History

Wellness Survey

Informed Consent & Confidentiality Policy

Informed Consent & Confidentiality Policy

Informed Consent & Confidentiality Policy

Informed Consent & Confidentiality Policy

Informed Consent & Confidentiality Policy

Agreement and Understanding

Financial Agreement

Financial Agreement

Signature