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

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NEW CLIENT INFORMATION/CONSENT FORM Sally LeBoy, MS, MFT Lic# MFT14768 Welcome to my practice. Please take a few minutes to fill out the following form. This information will enable me to better meet your needs. Thank you for your time. Client Name: (To be completed by the Parent/Guardian if patient is younger than 18 years) Today s Date Date of Birth Age Address Street address City State Zip Email Address I do not wish to receive emails Phone Number(s): Home Work Cell May we call you...at home? yes no...at work? yes no Current Relational Status: Single Married - Date Co-habitating-Date Prior Marriages: Separated - Date Widowed-Date Please list all prior marriages, including the date of marriage and date of divorce: Please list all of your children: Employer/School Occupation Referred by: It is our policy to acknowledge all referrals with a thank you card. If you do not want your referrer to be contacted, please check here.! Person to be contacted in case of an emergency Home phone: Relationship Work phone:

Presenting Problem(s): Please describe your reasons for seeking counseling (include date/month the problem started): Please list any serious medical conditions that you are or have been treated for: When did you last have a physical examination? Who did you see? Name Phone Number Page 2

PLEASE INDICATE ANY AREAS OF CONCERN TO YOU AT THIS TIME: Marriage/Relationship Family Job/School performance Friendships Hobbies Financial Situation Physical Health Anxiety level/nerves Depression Suicidal Ideation Mood Eating Patterns Sleeping Patterns Sexual functioning Ability to concentrate Ability to control your temper Please list any medications that you are currently taking: Please describe any current or past problems with substance abuse: Please give a brief description of any previous therapy experiences you have had including substance abuse treatment.. Page 3

Please add any information that you would like me to know that is relevant to your treatment.. Page 4

Confidentiality All information between counselor and patient is held strictly confidential unless: 1. The client authorizes release of information with his/her signature. 2. The client presents a physical danger to self. 3. The client presents a physical danger to others. 4. Child/elder abuse/neglect is suspected. In the latter two cases, I am required by law to inform potential victims and legal authorities so that protective measures can be taken. Clients whose costs are covered by insurance should be aware that coverage always requires a diagnosis. Some insurance companies require even greater information in order to complete treatment reports. Any treatment reports will be discussed with you. It is assumed that by requesting the completion of an insurance form you are granting permission to fill out the necessary information concerning diagnosis and treatment. Questions regarding your insurance company s policies on confidentiality should be taken up with the company directly. Financial Terms The hourly therapy fee is $150. unless other arrangements have been made. Full payment is due at each session. While some insurances may cover a portion of the fee, payment is the responsibility of the client. Assistance with the billing of insurance carriers will be provided at no fee by the therapist. Check, cash or most credit cards are accepted. If you wish to use a credit card or electronic check, please fill out the last page of this intake form. Canceled/Missed Appointments A scheduled appointment means that time is reserved only for you. If an appointment is missed or canceled with less than 24 hours notice, the client will be billed according to the scheduled fee. Missed appointments are not covered by insurance and are the responsibility of the client. Sessions are 50 minutes in length unless otherwise scheduled. Consent for Treatment I authorize and request that Sally LeBoy, MS, MFT, provide psychological examinations, treatments, and/or diagnostic procedures which now or during the course of my care as a client are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable. Signature of Client (or parent/guardian) Date Signature of Therapist Date Page 5

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