Linda Cochran, LCSW INDIVIDUAL INTAKE

Similar documents
Miracles Counseling Centers, INC. Therapist Name: Date: Individual Intake. Client s name: Address: Emergency Contact: Telephone: Referred By:

Family & Psychological Services Inc. Greentree Commons 951 Route 73 North, Suite B Marlton, NJ 08053

Adult Registration Form

COUNSELING FOR EMPOWERING CHANGE

Adult Intake Form. Counselee Name. Last First MI Male Female. Address: Street (or P.O. Box) Apt. # City State Zip Code

Stacy Harris LMFT. Address: City: Zip Code: Phone: Date of Birth: Soc. Sec. # Employer: Work Phone: Okay to call Yes / No

HOPE COUNSELING CENTERS Winter Haven Office 160 Ave E., N.W. Winter Haven, FL CHILD CLIENT INTAKE FORM (Please print)

ADULT SELF ASSESSMENT

CLIENT CONSENT FORM / PRIVACY NOTICE

Adult Intake Questionnaire

INSURANCE INFORMATION - ADULT FORM It is important that you thoroughly complete this form and provide a copy of both sides of your insurance card(s).

of Springfield Client Intake Information: Adolescent

Joliet Center for Clinical Research

Bailey Behavioral Health, LLC Treatment Questionnaire

PAMELA RAK, LCSW, P.C. INTAKE FORM (Please print clearly)

Patient Name (Please Print)

Name: last First middle Address: street city state zip code Mailing Address: ( if different) street city state zip code

Joanne Jones, MSW, M.A. Licensed Marriage & Family Therapist

NORTH RALEIGH PSYCHIATRY, P.A. PATIENT REGISTRATION SHEET

Keri. Connections Family Therapy, LLC. Keri L Christensen LISW 1310 Tower Lane NE, Cedar Rapids, IA 52402

COUNSELING SERVICES AGREEMENT. Counseling Fees. Private Pay

NEW CLIENT INFORMATION/CONSENT FORM Sally LeBoy, MS, MFT Lic# MFT14768

Oliver Winston Behavioral Urgent Care, LLC

Therapist Name: Last Name: First: Middle: Address: City: State: Zip: Home Phone: Mobile Phone: Work Phone: If yes, Preferred Phone Home Work Mobile

BALDWIN COUNSELING S. Lynnhaven Rd. STE. 102 Virginia Beach, VA Office: (757) Fax: (757)

CARD AUTHORIZATION (J:J!.CN, Debit, Health Savings Account, etc.)

Application Date: MONTGOMERY COUNSELING CENTER th Ave Rd Nampa, ID Telephone: (208) ; Facsimile:

VIJAPURA BEHAVIORAL HEALTH, LLC 9141 Cypress Green Drive, Ste 1 Jacksonville, FL Phone: Fax:

1 Oglethorpe Professional Blvd. Suite 201 Savannah, Ga Phone (912) Fax (912) A BRIEF STATEMENT REGARDING FEES

PATIENT FINANCIAL AGREEMENT

Welcome to Savannah Psychiatry

Patient Registration Form

New Client. Address: City: State: Zip: Contact # s Home: Work: Social Security#: / / Date of Birth: / / Age: Name: Address: City: State: Zip:

Betty Kratzenberg, MS, LMFT INITIAL CLIENT INFORMATION

Patient Registration Form

Patrick A. Quigley, Ph.D., LSAC

Last Name: First Name: Middle Initial: Address: City: State: Zip: Home Phone: Work: Cell: SSN: Sex: Birthdate: Marital Status:

New Patient Information Form Advanced Behavioral Health Center PATIENT INFORMATION

Child/Teen Counseling Intake Form

Kinsler Psychology Help when life hurts

INTAKE FORM Please print and give complete information

GEORGE P. GLASER, LCSW

Chiropractic Case History/Patient Information

Client Contract. Client Full Name: Social Security Number: POA/Guardian Name: Phone: Address:

Samuel W. Sentell, Ph. D. MP Licensed Medical Neuropsychologist 1513 Line Avenue Suite 127 Shreveport, LA Phone: or

STUDENT STATUS: FULL TIME PART TIME NOT A STUDENT RESPONSIBLE PARTY: SELF GUARANTOR RELATIONSHIP

4601 Spicewood Springs Rd., Office (512) Austin, Texas Fax (512) DOCTOR-CLIENT SERVICES AGREEMENT

Welcome To Our Office

Welcome to View Point Health. We are honored to partner with you on your recovery journey. Please give us your Name:

PATIENT INFORMATION DATE: / / SS # - - DOB: / / NAME: (last) (first) (middle) ADDRESS: CITY: STATE: ZIP: PHONE (HOME): (CELL):

Please review the attached document and complete and sign the Acknowledgement of Receipt of Privacy Practices.

MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information

Our office is located at 501 Darby Creek Road, Suite 21 in Lexington. This is just off Man- O-War Blvd, between Palumbo Drive and Mapleleaf.

Center for Emotional Wellness & Healing, LLC 100 Heritage Valley Rd, Ste. 1, Sewell, NJ 08080

NOTICE TO OUR PATIENTS

Please complete all pages prior to your first appointment. Thank you. CHILD/ADOLESCENT CLIENT/PATIENT/EXAMINEE INFORMATION.

Patient Name: First Middle Last Address: Number Street (Apt#) City State Zip Address: Okay to Statement? Yes No

Kelly Murray MA, LPC 4531 SE Belmont St #203 Portland, OR Ph#

PROFESSIONAL COUNSELING ASSOCIATES

SunDance Behavioral Resources, LLC Adult Registration & History Form

Patient Information. Primary Care Physician: Last Name: First Name: MI: Address: City/ST/Zip code: Home Phone :( ) Cell Phone: ( ) Leave Message

Demographics/Authorization Page (Front and Back) Patient Medical History Testing History Privacy Consent Form/ Financial Agreement (Front and Back)

WELCOME TO BRAZOSPORT CARDIOLOGY Office of Dr. Scott Harris and Dr. Nabil Baradhi INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION

Patient Information. Patient Name: Address . City State Zip. Birthdate Sex: Female Male Marital Status: Married Single Other

Please complete entire form

Registration Information

Please turn over and sign page 2

Wilderness Treatment Center 200 Hubbart Dam Rd. Marion, MT (406) (406) fax

PETER A. POWERS, PH. D. 511 East 12 th Avenue Eugene, OR CLIENT RIGHTS AND RESPONSIBILITIES

Spouse/Parent s Name Date of Birth / / Age Sex Relation to client Social Security # Phone Employed by Phone

Client Intake Face Sheet

Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -

Jean Manz Coaching and Counseling, LLC

PSYCHOTHERAPIST-CLIENT SERVICE AGREEMENT

Heidi Lasser, LCPC 3709 N. Locust Grove Rd., Ste 100 Meridian, ID 83646

HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION

CLIENT INFORMATION SHEET. Name Date of birth / / Age. Address. City/State/Zip Home Phone. Address Cell/Work Phone. Occupation Employers Name:

Milestone Psychiatric & Psychological Services, P.C. (Comprehensive Psychiatric & Psychological Services)

North End Psychiatry & Associates

CONTACT INFORMATION Please Print

WELCOME TO OUR OFFICE. Patient s Name: Today s Date: First Middle Last. Home Address: City: State: Zip: Telephone: Home ( ) Cellular: ( ) Work: ( )

***Credit/Debit Card Policy***

MoDOT & Patrol Employees Retirement System MPERS Disability Benefits Claim Packet Instructions

PATIENT INFORMATION Patient Name: Last First Middle Initial. Address. Street or P.O. Box City, State Zip

MARTIN S PEDIATRICS AND FAMILY CARE: ADULT CHECK IN FORM

PATIENT REGISTRATION / INFORMATION SHEET

Continued on Next Page

PATIENT REGISTRATION FORM Patient Information. Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: Address: Street

Patient Registration

Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA

AUTHORIZATION FOR TREATMENT

HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information

Parent/Guardian Name: Social Security #: Male / Female: Date of Birth: / / Home Phone: Mobile Phone: Work Phone: Street Address: City: State: Zip:

PSYCHOLOGIST-PATIENT SERVICES AGREEMENT

Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.

CLIENT INFORMATION SHEET

Client Services Agreement/Informed Consent Form

Geoffrey Steinberg, Psy.D.

Name. Name. Name Employer Occupation Relationship to patient Work Phone Ext. # DOB Soc. Sec. # Home Phone Cell Phone Address

Transcription:

Linda Cochran, LCSW INDIVIDUAL INTAKE CLIENT'S FULL NAME: TODAY'S DATE: ADDRESS: STREET OR P.O. BOX CITY STATE ZIP TELEPHONE: HOME CELL WORK AGE: BIRTHDATE: SSN#: MARITAL STATUS: DRIVER'S LICENSE#: EMPLOYER OR SCHOOL (IF STUDENT): REFERRED BY: PHONE: PERSON WHO DOES NOT LIVE WITH YOU TO CONTACT IN AN EMERGENCY: NAME RELATIONSHIP PHONE INSURANCE INFORMATION INSURANCE COMPANY: INSURED'S SSN#: NAME OF INSURED: INSURED'S D.O. B.: INSURED'S POLICY #: INSURED'S GROUP #: INSURED'S EMPLOYER: AMOUNT OF CO PAYS: INSURED'S RELATIONSHIP TO CLIENT: AUTHORIZATION #: IF YOUR COUNSELING IS BEING PAID FOR THROUGH AN EMPLOYEE ASSISTANCE PROGRAM, PLEASE LIST AUTHORIZATION NUMBER AND HOW MANY SESSIONS ARE BEING AUTHORIZED. EAP COMPANY AUTHORIZATION NUMBER # OF SESSIONS CO PAYMENTS ARE DUE AT THE TIME OF SERVICE. I HEREBY ASSIGN PAYMENT OF INSURANCE BENEFITS DIRECTLY TO LINDA COCHRAN, LCSW. WHILE LINDA COCHRAN, LCSW WILL BILL MY INSURANCE COMPANY, I WILL BE RESPONSIBLE FOR ANY CHARGES INCURRED IF MY INSURANCE COMPANY DOES NOT PAY. IT IS MY RESPONSIBILITY TO CONTACT MY INSURANCE COMPANY TO OBTAIN THE PROPER AUTHORIZATIONS IF REQUIRED. IF I FAIL TO DO THIS AND CHARGES ARE DENIED I WILL BE RESPONSIBLE FOR ALL CHARGES. CLIENT SIGNATURE: Primary diagnosis DATE: To be completed by therapist: Secondary diagnosis

2. TO ENABLE MY THERAPIST WITH ACCURATE AND CONFIDENTIAL SERVICES PLEASE COMPLETE THE FOLLOWING: THE FOLLOWING INDIVIDUALS MAY SCHEDULE AND OR CONFIRM APPOINTMENTS. MESSAGES REGARDING APPOINTMENTS MAY BE LEFT ON MY VOICE MAIL. YES NO MILITARY HISTORY: Branch: Years: Rank: Active/Inactive/Retired status: Discharged: Y or N and Status: Deployments and where: Other: MARITAL INFORMATION: MARRIED: DIVORCED: LIVING TOGETHER: SEPARATED: SINGLE: OTHER: IF YOU CHECKED "OTHER" PLEASE EXPLAIN: UST DATES AND LENGTHS OF ANY PREVIOUS MARRIAGES: FAMILY HISTORY: LIST THE NAMES, AGES, AND RELATIONSHIP OF ALL PERSONS LIVING IN YOUR HOME: LIST THE NAMES, AND AGES OF ANY IMMEDIATE FAMILY MEMBERS THAT ARE NOT LISTED ABOVE YOU A DANGER TO SELF OR TO 0 I-HERS? :ARE YOU IN ANY DANGER FROM OTHERS? IF SO kivho AND HOW? HAS SUICIDE EVER BEEN THOUGHT OP? At ri 1:'REV/101.,/$ ATTEVOPTS'? (WHEN. I IOW, CIUTCCOIE) ANYONE. IN YOUR FAMILY COMMIT EABCIDE? IF SO, kiv1-10 AND WHEN:

PLEASE CHECK INDIVIDUAL ITEMS YOU WANT TO ADDRESS. CONCENTRATION FEARS BOWEL TROUBLE SELF-ESTEEM HOPELESSNESS GUILT STOMACH TROUBLE TEMPER DEPRESSED SELF-CONTROL SEXUAL PROBLEM RELAXATION HARM TO SELF HARM TO OTHERS DRUG USE FINANCES SUICIDAL CONCERNS IMPULSIVITY ALCOHOL USE WORK HIGH ENERGY HYPERACTIVE HEADACHES MOTIVATION LOW ENERGY ATTENTION DIFFICULTIES MEMORY LEGAL MATTERS ANGER SLEEP PROBLEMS THOUGHTS CAREER CHOICES TEMPER DREAMS ABUSE EDUCATION NERVOUSNESS NIGHTMARES TRAUMA MAKING DECISIONS ANXIETY HEALTH PROBLEMS SHYNESS MEANINGLESSNESS STRESS APPETITE/WEIGHT CRYING SPELLS UNRESOLVED GRIEF PANIC EATING/FOOD TROUBLE UNHAPPINESS SPIRITUAL CONCERNS PLEASE CHECK RELATIONSHIP ITEMS YOU WANT TO ADDRESS. MARRIAGE PARENTING RECREATION FRIENDSHIPS SEPARATION CHILDREN INFIDELITY/AFFAIRS HOLDING OTHER DOWN DIVORCE HOUSING PHYSICAL FIGHTING CONFLICTING SCHEDULES INTIMACY FINANCES COMMON INTERESTS PROBLEM SOLVING IN-LAWS SEXUAL DESIRE SHOWING APPRECIATION LONELINESS RELATIVES AGREEING ON CHORES TRUSTING EACH OTHER COMMON GOALS JEALOUSY SEXUAL PERFORMANCE AFFECTION VERBAL FIGHTING USE OF TIME SPOUSE'S CLEANLINESS COMMUNICATION HAVING FUN TOGETHER HEALTH INFORMATION: LIST ALL CURRENT MEDICATIONS: 3. LIST ALL CURRENT HEALTH PROBLEMS INCLUDING ALLERGIES: LIST PAST SIGNIFICANT HEALTH PROBLEMS: HAVE YOU BEEN HOSPITALIZED OR HAD OTHER PSYCHIATRIC CARE RELATED TO YOUR MENTAL HEALTH? IF YES PLEASE PROVIDE DATES AND TREATMENT OUTCOME FOR THOSE EVENTS: LIST PREVIOUS PROFESSIONAL HELP, AND DATES YOU RECEIVED FOR PERSONAL, MARITAL, OR FAMILY CONCERNS: NAME OF YOUR PRIMARY CARE PHYSICIAN: MAY WE CONTACT? PHONE NUMBER: WHEN WERE YOU LAST SEEN? I GIVE MY CONSENT FOR MY THERAPIST TO RELEASE MY RECORD TO MY PRIMARY PHYICIAN SO THAT THEY CAN DISCUSS MY TREATMENT: SIGNED DATE I DO NOT GIVE MY CONSENT FOR MY THERAPIST TO RELEASE MY RECORDS TO MY PRIMARY CARE DOCTOR TO DISCUSS MY TREATMENT: SIGNED DATE

DRUG AND ALCOHOL ASSESSMENT: Are drugs or alcohol used by yourself or someone else a significant factor in why you are coming to our office? _yes no If yes self other: Relationship ALCOHOL ASSESSMENT: Frequency of Alcohol use: Never Less thanl time/month 1-4 times per month 2-3 times per week Daily Usual Alcohol Consumption: None 1-2 drinks per sitting 3-4 drinks per sitting 5 or more drinks per sitting Frequency of use to levels of intoxication: Never less than 1 time/month 1-4 times per month 2-3 times per week Daily Please describe any alcohol-related problems (e.g. legal, job, physical, or social): 4. Self-perception of alcohol use: (check all that apply) Occasional or social T Problem use Psychological dependence Addicted-cannot stop Does not want to stop Motivated to stop History of treatment attempts: (check all that apply) None Stopped on own Attended AA/ other 12 step program Attended outpatient program ^ Attended inpatient program Attended community-based program --4013Used OTHER SUBSTANCE USE ASSESSMENT: (Check Frequency and Duration for each drug used in the lost 6 months) Frequency Duration Marijuana Sedative Stimulant Cocaine Opiates Inhalants Hallucinogens Prescription Drugs Daily Weekly Monthly Less than More than Or less one year one Year Caffeine Number of cups per day Tobacco if cigarettes-number per day Please describe any drug-related problems (e.g. legal, job, physical, or social) Self-perception of Drug Use: (check all that apply) Occasional or social Problem use Psychological dependence Addicted-cannot stop Does not want to stop Motivated to stop History of treatment attempts: (check all that apply) None Stopped on own Attended NA/ other program Attended outpatient program Attended inpatient program T Attended community-based program

Linda T. Cochran, LCSW 840 Fleming St, Hendersonville, NC 28791 828-693-1958 Client Statement of Understanding(Initial all that apply): I understand that I am responsible for knowing my Mental Health benefits as defined by my insurance company, such as: the name of my insurance company or employee assistance program, deductible information for Mental health services, and my co-pay amount per session. I understand that I must provide a current health insurance card before services can be rendered. I understand that I will be charged a $5.00 fee per session for providing information that is incorrect regarding the name of the insurance company that provides my Mental Health coverage, The charge would be to cover the refilling of insurance to another company that I later learn from my insurance company administers my Mental Health benefits. I understand that I will $35.00 fee for failure to show for an appointment or if I cancel with lass than a 24 hour notice. Emergencies are: sickness, auto problems, required to work over on a job and weather. They are excluded but must be reported as son as possible to avoid a same day bill being sent to me. Linda T. Cochran, LCSW, agrees to file with my insurance in good faith that I have provided accurate and current information to her for proper billing of my Mental Health insurance. A copy of this was given to me. Any questions I had were explained to me. Signature Date

2024 © financedocbox.com Privacy Policy | Terms of Service | Feedback