Client Information Form for Telemental Health Client Information Form for Telemental Health This sheet must be filled out completely. Couples seeking counseling must submit two forms, one per person. First Name * Last Name * Sex Male Female Date Of Birth Address City State/Province Zip/Postal Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Cell Phone Is it Okay to leave a message on Cell? Yes or No? Home Phone Is it Okay to leave a message on Home phone? Yes or No? Work Phone Is it Okay to leave a message on Work phone? Yes or No? Email Address Okay to contact you via this Email? Yes or No? Emergency Contact : NAME Emergency Contact : PHONE NUMBER Legal Status Single Married Separated Divorced Widower Minor (Under 19 years) Occupation Employer/ School Education ( Highest Level) Graduation Year Current Living Situation Alone With Spouse/ Partner With Parents With Children Other Spouse/ Partner/ Guardian name Phone Number Address City State/Province Zip/Postal Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Country Person responsible for Payment Birth Date Name of Child Age Sex Male Female School/College/Employed Living with you? Yes No Name of Child Age Sex Male Female School/College/Employed Living with you? Yes No Name of Child Age Sex Male Female School/College/Employed Living with you? Yes No Name of Child Age Sex Male Female School/College/Employed Living with you? Yes No Name of Child Age Sex Male Female School/College/Employed Living with you? Yes No Reasons for considering counseling at this time: Are currently involved in the legal system? Yes No If Yes, Please give details: What do you expect from therapy? How did you hear about me? (Or from whom)? Counseling and Medical History Are you in treatment with another counselor at this time? Yes No If Yes', with whom? Have you or (or spouse) ever received counseling in the past? Yes No If Yes, When and Where? Have you ever been hospitalized for any mental health reasons? Yes No If Yes, When and Where? Please list any current addictions to behaviors or substance (porn sex, video gaming, internet, drugs, food, gambling, shopping, etc. Are you currently under a physician’s care for physical problems? Yes No If Yes, Please give details: Current Medications: Name of physician Phone number What was the result Contact Agreement Phone calls and emails will be responded to within 48 hours. I understand and agree Therapy Service and Financial Agreement Rights and Risks: Please feel free to ask questions about any aspect of the counseling process. If you have been referred by a court or state agency you have the right to divulge only what you want to be included in a report. You need to be willing to discuss what troubles you and be open to change. As a result of counseling, you may remember unpleasant events, arouse intense emotions, and/or alter relationships. Confidentiality: Confidential Information shared will be held in confidence in compliance with applicable state and federal law. “Confidential Information” includes any recordings or transcripts of therapy sessions, therapist notes, medical reports or therapy progress reports. Information will not be released without your written consent, except for professional consultation if needed or if disclosure is required by law. Your therapist is required by law to disclose information pertaining to suspected child abuse, or elder abuse, inability to care for one’s basic needs for food, clothing or shelter, and threatened harm to oneself or others. Should your therapy be involved or be the subject of court proceedings or litigation, your counseling records may be subject to subpoena. It is understood that information regarding treatment and diagnosis may be provided to an insurance company. You may want to discuss further limits or exceptions of confidentiality. Appointments: All office visits are by appointment with your therapist directly. Your appointment is either 30 minutes or 45 minutes as per your contractual preference. Late cancellation (Less than 24 hours before) and/or no-show appointments are billed to the client at a rate of $60 per missed session. In the case of illness, please notify us no later than 9 am the day of the appointment. Please leave a message if you get the voice mail. If your appointment is cancelled or missed, contact your therapist for a new appointment time. I acknowledge that I received, read and understand the Therapy Service Agreement. By signing below I agree to the terms of the agreement: Client/Gurdian Signature Date Phone calls and emails will be responded to within 48 hours. I understand and agree Privacy Practices (HIPPA) I may use or disclose PHI (protected health information) for purposes outside of treatment, payment, or health care operations with your authorization. In those instances when we are asked for information for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes that some providers choose to make about conversations during a private, group, joint, or family counseling session, which are kept separate from the rest of your record. These notes include recordings and transcripts of any therapy sessions. These notes are given a greater degree of protection that PHI. You may revoke all such authorization (of PHIS or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have taken some action in reliance on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, as applicable state and federal law provides the insurer the right to contest the claim under the policy. We may use your disclose PHI without your consent or authorization in the following circumstances: Child Abuse – If we have reasonable cause to believe a child known to us in our professional capacity may be an abused child or a neglected child, we must report this belief to the appropriate authorities. Adult and Domestic Abuse – If we have reason to believe that an individual protected by state law has been abuse, neglected, or financially exploited, we must report this belief to the appropriate authorities. Worker’s Compensation – We may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws retaining to worker’s compensation or similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault. Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis and treatment and the records thereof, such information is privileged under state law, and we must not release such information without a court order. We can release the information directly to you on your request. Information about all other psychological services is also privileged and cannot be released without your authorization or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is pursuant to court order. You will be informed in advance if this is the case. Serious Threat to Health or Safety – If you communicate to us a specific threats of imminent harm against another individual or if we believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, we may make disclosures that we believe are necessary to protect that individual from harm. If we believe that you present and imminent, serious risk of physical or mental injury or death to yourself, we may make disclosure we consider necessary to protect you from harm. I have read and understand the above HIPPA guidelines. Client/Gurdian Signature Date
