Online Adult Form — Bridge of Hope Counseling Center
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Our Services
Our Counselors
Client Forms
Request Appointment
Adult New Client Intake Form
Please complete All Fields Of the form below.
Patient Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Work Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Is it ok to leave a voicemail message?
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Yes
No
Which phone is ok to leave a voicemail message on? ( Check all that apply)
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Home
Work
Cell
Email
*
Referred By:
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In Case Of Emergency Call:
*
Emergency Contact Phone Number
*
(###)
###
####
Your Employer:
*
How long have you worked there?
*
What is your postion or title?
*
What is the last year of school completed?
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9
10
11
12
GED
Undergraduate Degree
Graduate Degree
What is your marital status?
Single, never married
Engaged
Living together without marriage
Separated
If separted how long?
Marital Status Continued
Divorced
Widowed
Married
If divorced how long?
If widowed how long?
If married how long?
Spouse Name
Spouse Age
Spouse Occupation
Total number of marriages for you?
Total number of marriages for your spouse?
Please list the names, ages, and genders of all of your children?
Which children are living at home?
Have you ever attempted suicide in the past?
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Yes
No
If yes how?
Is there a history of suicide in your family?
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Yes
No
Have you ever inflected burns or wounded to yourself?
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Yes
No
Are you presently suicidal or homicidal?
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Yes
No
What events in your recent past have prompted you to seek counseling?
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What is your main concern for seeking counseling?
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Are you currently attending church?
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Yes
No
If yes where?
Are your spiritual beliefs an important part of your life and decisions?
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Yes
No
How did you hear about us?
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Who is your family doctor?
*
How would you rate your health?
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Excellent
Good
Fair
Poor
Are you currently on medication?
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Yes
No
If yes please list all medications name, dosage, frequency, and perscribing doctor's name:
Please list and health problems, operations, and/or medical hospitalizations. Include the problems, dates, and types of treatments:
Have you been to counseling before?
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Yes
No
If yes where/who did you receive counseling?
How long did your receive previous counseling?
What year did previous counseling start?
Have you ever been admitted to the hospital for mental health or addiction issues?
*
Yes
No
If yes where?
If yes how long?
If yes what year was that received?
Name of current doctor or therapist:
List all medications you have taken in the past for anxiety, depression, and/or sleep:
Check any/all of the following lossed you have experienced:
Family
Health
Disruption of lifestyle
Job
Significant other
Other
If other please explain:
What is your main concern that brought you to counseling?
*
How much are you troubled by this main concern?
*
Constantly
Often
Somewhat
Not very much
What are your strengths as a person?
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What are your weaknesses as a person?
*
List the members of your family of origin and how you got along with each one:
*
How many siblings do you have?
*
What is your birth order in relationship with your siblings?
Who primarily raised you?
*
How would you describe your childhood?
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Traumatic
Painful
Uneventful
Please list any unusual or traumatic experiences for you as a child. Please include the dat, how old you were and what happened:
Check any/all problems that concern you now:
*
Spouse
Children
Parent
In-laws
Co-workers
Friends
Alcohol
Street drugs
Perscription Drugs
Binge eating
Excessive dieting or exercise
Shopping
Work too much
Procrastination
Communication
Depression
Anger
Grief
Gender Identity
Sex
Career
Lonliness
Mood swings
Self-esteem
Codependency
Stress
Fear
Anxiety
Feelings about God or church
Other
If other please explain:
Please check how oftern the follwing thoughts occur in you: Life is hopeless
*
Never
Rarely
Sometimes
Frequently
I am lonely
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Never
Rarely
Sometimes
Frequently
No one cares about me
*
Never
Rarely
Sometimes
Frequently
I am a failure
*
Never
Rarely
Sometimes
Frequently
Most people don't like me
*
Never
Rarely
Sometimes
Frequently
I want to die
*
Never
Rarely
Sometimes
Frequently
I want to hurt someone
*
Never
Rarely
Sometimes
Frequently
I am so stupid
*
Never
Rarely
Sometimes
Frequently
I am going crazy
Never
Rarely
Sometimes
Frequently
I can't concentrate
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Never
Rarely
Sometimes
Frequently
I am so depressed
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Never
Rarely
Sometimes
Frequently
God is disappointed in me
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Never
Rarely
Sometimes
Frequently
I can't be forgiven
*
Never
Rarely
Sometimes
Frequently
Why am I so different?
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Never
Rarely
Sometimes
Frequently
I can't do anything right?
*
Never
Rarely
Sometimes
Frequently
People hear my thoughts
*
Never
Rarely
Sometimes
Frequently
I have no emotions
*
Never
Rarely
Sometimes
Frequently
Someone is watching me
*
Never
Rarely
Sometimes
Frequently
I hear voices in my head
*
Never
Rarely
Sometimes
Frequently
I am out of control
*
Never
Rarely
Sometimes
Frequently
Please check the symptoms and behavior that occur in you more often that you would like them to:
*
Agression
Alcohol dependence
Anger
Antisocial behavior
Anxiety
Avoiding people
Chest pain
Depression
Disorientation
Distractibility
Dizziness
Drug dependence
Eating disorder
Elevated mood
Fatigue
Hallucinations
Heart palpitations
High blood pressure
Hopelessness
Impulsitivity
Irritability
Judgment errors
Loneliness
Memory impairment
Mood shifts
Panic attacks
Phobias/fears
Recurring thoughts
Sexual difficulties
Sick often
Sleeping problems
Speech problems
Suicidal thoughts
Thoughts disorganized
Trembling
Withdrawing
Worrying
Other:
If other please explain:
*
In typing your name below you affirm that all the information given in this form is true and complete.
*
Date Signed
*
MM
DD
YYYY
Signed for minor:
Thank you for choosing this office for your counseling needs. We are committed to giving you the highest quality of care. To assist you in understanding the policies of this office, we are providing the following information. Appointments: If an appointment must be cancelled, a minimum of 24 hours notice is required; otherwise, you will be charged a $50 fee. To cancel or reschedule an appointment, please call: (972) 937-1984. If a client misses two appointments without notification of cancellation the therapist may no longer treat them. Emergencies: In case of an emergency call (972) 937-1984. If the counselor you are calling is in session, leave a message and they will return the call as soon as possible. If the situation is such that it cannot wait for a returned call or it is outside the time frame of your counselor’s business hours, dial 911. Financial Responsibility: We require payment at the time of services rendered. Credit Card, Cash, check or money order are acceptable forms of payment. I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and provider of any services or treatments I receive. I understand that if pay for services is not rendered, the therapist may stop treatment. I also understand that my relationship with the counselor is professional in nature. The counselor is not able to participate in any kind of dual-relationship outside the office. Please sign below to indicate that you have read and understand the above procedures and are consenting to receive treatment under these terms.
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Date Signed
*
MM
DD
YYYY
This form is an agreement between you, and me/us, When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name here: When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls “protected health information” (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, to help carry out certain business or government functions, or to help provide other treatment to you. By signing this form, you are also agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explains in more detail what your rights are and how we can use and share your information. If you do not sign this form agreeing to our privacy practices, we cannot treat you. In the future, we may change how we use and share your information, and so we may change our notice of privacy practices. 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 promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing to our privacy officer. 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. Type your name for signature of client:
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Date Signed
*
MM
DD
YYYY
Relationship to client (If necessary)
I have had the opportunity to have any questions I may have answered. I do hereby seek and consent to take part in the treatment by the therapist named below. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. Informed Consent Statement for Psychotherapy and Counseling Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights that are important for you to know because this is your therapy, focused on your well-being. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you also. Confidentiality With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or member of your family about concerns without your prior consent, but only when the situation is an emergency. I will always act to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend your therapy session with you – requests of this nature should take place no less than twenty-four (24) hours before the scheduled appointment. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). The following are legal exceptions to your right to confidentiality. I would inform you at any time when I think I will have to put these into effect: 1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim. 2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and/or Adult Protective Services immediately. 3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If, at that point, you are unwilling to take steps to guarantee your safety, I would call the crisis team. 4. If you and your spouse decide to have some individual sessions as part of the couples’ therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your spouse. Typing below shows that I understand and agree with all of these statements.
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Date Signed
*
MM
DD
YYYY
Relationship to client ( If necessary)
Patty McGinnis counseling services, PLLC, Karen Powell, LPCS, PLLC, and Robert Saenz, LPC-LLC are separate entities sharing the assumed name “Bridge of Hope Counseling Services,” PLLC. Therefore, each entity is only liable for services offered or provided by the respective entity. The entities shall not be held jointly liable for services offered or provided solely by one entity or the other. By signing this form, you acknowledge that you have read this disclaimer and agree to the terms contained herein. I am seeing:
*
Patty McGinnis, LPCS
Karen Powell, LPCS
Robert Saenz, LPC
Typing my name below shows that I understand and agree with all these statements.
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Date Signed
*
MM
DD
YYYY
I understand that my records are protected by civil law in the State of Texas and all communications with a mental health professional are considered privileged. Certain records are also protected by the Federal Privacy Act of 1974 and HIPPA. I understand that information about me may not be released or obtained without written consent. Substance abuse information and any information regarding AIDS status must be consented to specifically and indicated below. I also understand that I may revoke this consent at any time except to the extent that action has already been taken. Name of client:
*
Client Date of Birth
*
MM
DD
YYYY
I hearby authorize (Your BOH Counselor's Name):
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Fax Number
(###)
###
####
To exchange information with: (Name of person you authorize BOH to exchange information with):
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Fax Number
(###)
###
####
Information sharing is limited to the following types of information:
For the purpose of:
Type your name for signature to approve information sharing.
Name of minor (If approving this for a minor)
Date of signature
MM
DD
YYYY
Thank you!
