Counseling Intake Form

Emergency or Crisis Assistance

If you are in crisis, call:

988 (Suicide and Crisis Lifeline)
911 (Local Emergency Services)

Confidentiality Covenant

Kelly Muratorri, LPC/LMHC, will keep confidential the information discussed in counseling sessions. A written record of your sessions will be maintained. Note the following limits on confidentiality:

If information is disclosed regarding child, elder, or disabled abuse or neglect, reasonable efforts will be taken to report suspected abuse to the appropriate agency.
If information is disclosed regarding any suicidal intent on the part of the client, the counselor reserves the right to take appropriate measures to ensure the safety of the client.
If information is disclosed regarding any homicidal intent on the part of the client, the counselor reserves the right to take measures to ensure the safety of the intended victim(s).
If subpoenaed or ordered by a court to disclose information, certain information may be shared.
If a client directs information to be shared with someone else and the release included below is signed by the client.
If and when information is disclosed regarding sexual exploitation by a previous counselor.
If deemed appropriate, and with the written consent of the client, the counselor may seek advice from another counselor, pastor, or licensed professional to meet the client’s needs.

I have read and understand this disclosure of information regarding counseling with Kelly Muratorri, LPC/LMHC. I have read and understand the following basic rights:

The right to be informed of the various steps and activities involved in receiving services.
The right to confidentiality under federal and state laws.
The right to humane care and protection from harm.
The right to make an informed decision whether to accept or refuse treatment.

Electronic signature (Type legal name)

Date signed

Informed Consent Acknowledgement

I understand that there can be no absolute guarantee of cure in the practice of counseling.

I understand that counseling is a cooperative effort between my counselor and me which may require homework outside of sessions.

I understand the risk that during the course of my treatment; material may be discussed which may be upsetting in nature.

When I schedule a session, that time is set aside for me. If I am not able to attend, I will provide notification at least 24 hours prior to the appointment time.

I understand there is a $75 fee for no-shows and cancellations without a 24-hour notice.

If I have not arrived within 15 minutes of my scheduled start time, I understand the session will be automatically canceled, and I will be charged the $75 no-show fee.

Beginning January 1, 2025, the no-show fee will increase to $100 to meet market demands.

Should I miss two sessions without notice, this will terminate my scheduled session time and I will be placed on the waitlist and invited to request a new time when my schedule allows.

I understand that I should delete all text and voicemail messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.

Electronic signature (Type legal name)

Date signed

Financial Information

Session times are 53 minutes. The out-of-pocket fee for sessions is $150. Client responsibility for this fee will likely decrease with insurance. Beginning January 1, 2025, the out-of-pocket fee for sessions will increase to $175 to meet market demands.

The fee to complete paperwork (e.g. FMLA, disability, etc.) is $125 per hour with a 2-hour minimum. The time required to print records, make copies, or or prepare and send mail, and any other administrative business (e.g. preparing releases of information) not directly related to the provision of clinical services, will also be assessed based on a rate of $125.

My fee for any requested appearance, subpoenaed appearance, settlement conference, or deposition is $500 per hour, with a minimum charge of two (2) hours. Such fees are due at least one (1) week before the scheduled appearance. If an appearance request is received without a minimum of one (1) week notice, the appearance fee is due immediately and there will be an additional $300.00 express charge. Failure to provide the fee as specified constitutes my release from the requested appearance.

Agreement

I request that Kelly Muratorri provide counseling services to me. I agree that this professional relationship will continue as long as the counselor provides services or until I notify I wish to terminate services.
I agree that I am responsible for all charges for services provided by Kelly Muratorri to me, although session rates are waived for clients receiving services through RVP.

Note Regarding Insurance

Third-party payers require the provision of a mental health diagnosis and supporting information to justify the need of services.
I make every effort to protect confidentiality, but I have no control over the confidentiality procedure of the managed-care plan.

Assignment and Release

I hereby authorize benefits to be paid directly to Kelly Muratorri where necessary.
I understand I am financially responsible for the aforementioned non-covered services and no-show fees.
I authorize Kelly Muratorri to release any information required to process claims.

Electronic signature (Type legal name)

Date signed

Client Information

To make our first meeting more productive, please give accurate and complete responses to every section of this form. All information is confidential as stated in the Informed Consent Form.

Today's date

First name

Last name

Last 4 of SSN

Date of birth

Age

ID or Driver's License Number & State

Gender

Phone number

Email address

Street address

City

State

Zip

May I call?

Yes No

May I email?

Yes No

May I text?

Yes No

May I leave a voicemail?

Yes No

If yes, please verify approved number/email. If no, what is your preferred method of communication?

Electronic Communications Consent

I consent to receive text messages or emails from Kelly Muratorri (“Provider”) on my cell phone or other devices. I understand that text messages and emails sent by Provider may include appointment reminders or changes in previously scheduled appointments, or may provide advice or education.

Provider does not charge for this service, but I understand that standard text messaging rates may apply as provided in my wireless plan. I will contact my carrier for pricing plans and details.

I understand that I may revoke my request for further communications via text or email at any time by notifying Provider in writing. However, if I continue to communicate with Provider via text or email, Provider can assume that my consent remains valid.

Because e-mails sent over the Internet or texts sent over the control channel without encryption are not secure, I understand the risks associated with e-mail and text messaging, including, without limitation, that e-mails and text messages could be intercepted by unknown third parties; e-mail content can be changed without the knowledge of the sender or receiver; backup copies of e-mail may still exist even after the sender and receiver have deleted the messages; and e-mail can contain harmful viruses and other programs.

Provider recommends that I delete all text messages or emails as soon as possible after reviewing them to limit any unauthorized exposure.

Signature (Type legal name)

Today's date

Telehealth Consent

What is Telehealth?

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services

I hereby consent to participate in telehealth with Kelly Muratorri as part of my care.

I understand that telehealth is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telehealth:

I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
There are risks, benefits, and consequences associated with telehealth, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
There will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
The privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).
If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.
Electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).
During a telehealth session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call or email me to discuss since we may have to re-schedule.
My therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.

I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.

I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided.

To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.

Signature (Type legal name)

Today's date

Emergency Contact

Add another emergency contact

In case of an emergency, do I have permission to contact this person?

Yes No

Counseling and Medical History

Have you previously received mental health counseling?

Yes No

If yes, provide description, duration, and counselor's name

Is there a history of mental illness in your family?

Yes No

If yes, list relation and illness

Are you presenting working with any other counselor?

Yes No

If yes, provide reason, duration, and counselor's name

Are you involved in family counseling or support group?

Yes No

If yes, provide reason, duration, and counselor's/group leader's name

Have you received a diagnosis by a mental health professional?

Yes No

If yes, please list any diagnosis

Have you been hospitalized for mental illness or substance use?

Yes No

If yes, provide details

Are you prescribed medication?

Yes No

If yes, what medications are you currently taking?

Do you attend church?

Yes No

What is your religious preference and how strong is the influence of church in your life?

Is spirituality important to you?

Yes No

When was your last physical by a doctor?

Briefly state the reason your are seeking counseling

Family History

If in a relationship, are you happy?

Yes No

Are you experiencing domestic violence?

Yes No

Is there anything regarding your relationship you would like to share?

Briefly describe your relationships with your parents/caregivers.

Do you have any children?

Yes No

If yes, briefly describe your relationship with your children.

Do you have any siblings?

Yes No

If yes, briefly describe your relationship(s) with your sibling(s).

Is there anything else regarding your family history you would like to share?

Personal History

Last grade completed

Are you currently employed?

Yes No

If yes, what is your occupation?

Do you use drugs?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you get quality sleep?

Regularly Occasionally Never

Do you make time for fun?

Regularly Occasionally Never

Do you exercise?

Regularly Occasionally No

Do you have a healthy diet?

Regularly Occasionally No

Is there anything else regarding your personal history you would like to share?

Concerns

If "other", please describe.

Marginalized Population Questions

Are you a military veteran?

Yes No

If yes, when and where did you serve?

Are you a first responder?

Yes No

If yes, where do you currently work/serve?

Are you a spouse of a veteran or first responder?

Yes No

If yes, where does/did your spouse serve?

Have you experienced prejudice?

Yes No

If yes, please explain.

Do you utilize pronouns?

Yes No

If yes, please provide.

Describe any goals or outcomes you hope to achieve from counseling.

Is there anything else you'd like to share?

Signature (Type legal name)

Today's date

Your information will be encrypted.

Counseling Intake Form

Emergency or Crisis Assistance

Confidentiality Covenant

Informed Consent Acknowledgement

Financial Information

Client Information

Electronic Communications Consent

Telehealth Consent

Emergency Contact

Counseling and Medical History

Family History

Personal History

Concerns

Marginalized Population Questions

Emergency or Crisis Assistance

Kelly Muratorri, LPC, LMHC