CLIENT INTAKE SCREENING FORM- ENGLISH

(404)585-7665 | luisalvarez@therapysecure.com | 1 Huntington Road, Suite #101, Athens, GA 30606

Instructions: Please complete the form below and click "Submit" once you are done entering all of the information. You will receive an automatic confirmation email after you submit the form. Please contact us if you have any questions or if you prefer a paper version of this form.

DEMOGRAPHIC INFORMATION

First Name

Last Name

Preferred Name(s)

Date of Birth

Age

Race/Ethnicity (check all that apply)

White/Caucasian

Black/African American

Hispanic/Latinx

Other not mentioned above

Race/ethnicity not listed, please specify:

Gender (please check all that apply)

Man

Woman

Transgender

Gender Fluid

Non-Binary

Agender

Other not mentioned above

Gender not listed, please specify:

Gender Pronouns

He/Him/His

She/Her/Hers

They/Them/Theirs

Other not listed above

Gender pronoun(s) not listed , please specify:

Sexual Orientation (please check all that apply)

Heterosexual/Straight

Lesbian

Gay

Bisexual

Queer

Asexual

Other not mentioned above

Sexual orientation not listed, please specify:

Languages spoken other than English

Religion/Spiritual Beliefs

Marital Status

Number of Children (if any)

CONTACT INFORMATION

Phone Number

Other Phone Number (optional)

How can we contact you? (check all that apply)

Call

Text

Please DO NOT leave a voice mail

Street Adress

City, State, Zip Code

Emergency Contact Person

Relationship to You

Emergency Contact Phone Number

MEDICAL HISTORY

Primary Care Provider or PCP (if any)

Contact Number of PCP

Medical Conditions (if any)

Medication(s) (Not for Mental Health)

Last Medical Hospitalization (if any)

Reason for last Medical Hospitalization

MENTAL HEALTH HISTORY

Psychiatrist (if any)

Contact Number of Psychiatrist

Mental Health Diagnosis (if any)

Medications related to Mental Health (if any)

Last Mental Health Hospitalization

Reason for Mental Health Hospitalization

Have you ever participated in counseling/therapy?

Yes

If yes, last time you were in therapy

If yes, Type of Therapy

Individual

Couples

Group

Other

If yes, Reason(s) for Therapy

If yes, Name of Therapist(s) or Agency

Was therapy/counseling helpful?

Yes

Somewhat

Not Sure

Please list other support services (NA/AA/CMA, support groups, case management, etc.)

WHAT BRINGS YOU IN?

What is happening or what are you experiencing that is leading you to seek services?

Did someone ask/tell you to come see us?

Yes

If so, who asked you to see us?

If someone asked you to see us, why did they tell you to come in?

What do you hope to gain/change/discuss by coming in?

What motivated you to come in?

What days/times are you available to meet?

Any other information your therapist should know?

CONSENT FORM

Please note the following policies and procedures. If you have questions about any of the following information, feel free to ask for clarification at your intake appointment. Please initial where indicated.

Informed Consent

I agree to be treated by the provider listed above. I understand that my participation in treatment is voluntary and that I can terminate services at any moment.
I also understand that if I am court-mandated to engage in services, my termination of services can affect my legal case. Engaging in services are in no way a guarantee of specific legal outcomes.

Your Initials

Confidentiality

The content of what is discussed within the confines of your session are confidential. As outlined in HIPAA, in most cases I cannot and will not disclose any of your personal information without your written consent.
The limitations of confidentiality include situations in which the counselor has reason to believe there has been an instance of child abuse or neglect, situations in which clients are deemed to be a threat to themselves or others, in case of emergency, or situations in which records are subpoenaed in a court of law.
Additionally, there may be times when it is necessary and beneficial for me to staff cases with colleagues, though when that need arises no personal or identifying information is shared.
To obtain a copy of certain parts of your record, please allow at least 7 days to process the written request. A Release of Information will need to be completed for every request.
A copy of the HIPAA Privacy Policy, which includes your rights and responsibilities can be found at multicolorwellness.com. You can request a paper copy of the Privacy Policy.

Your Initials

Court and Legal Matters

In cases that may involve court testimony, please be advised that my role is to help you and/or your family member find healing throughout this process. My priority is to honor the therapeutic relationship with you, as my client and it is not to gather evidence or to evaluate for custody, immigration cases, disability cases, or other legal disputes, unless otherwise agreed upon between the therapist and client.
Should you choose to subpoena me for court testimony in a civil or criminal case in order to testify as to my clinical experience with you or your family, the fee is $175 per hour, including travel and preparation time. Additional services, such as time spent speaking with attorneys or writing letters may entail an extra charge.
Please let your therapist know if you are currently working with an attorney, so that a Release of Information form can be completed and signed.

Your Initials

Telemental Health

I have completed specialized training in TeleMental Health and I have also developed several policies and protective measures to assure your PHI remains confidential. However, there are risks to the use of Telemental Health.
If we speak on the phone, there is a risk that someone may overhear or intercept our conversation. Additionally, if anyone has access to your cell phone bill they may be able to see that we talked, what date we talked, and for how long.
Text messaging is not a secure means of communication and may compromise your confidentiality. I do not utilize texting in my therapy practice for anything other than for scheduling purposes.
Email is not a secure means of communication and may compromise your confidentiality. Please know that it is my policy to utilize email strictly for appointment confirmations. If you are not using an encrypted email account, there is the risk, as with emailing any sensitive data, that that information may be intercepted by a third party.
Skype is not a HIPAA-compliant format for video chat sessions, but at times I use a HIPAA compliant therapy video conferencing website. If you’re interested in a telemental health session, I will give you directions on how to use this site.
Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI).
It is the client’s responsibility to use devices that are secure. The client assumes all risks associated with using email to send information.

Your Initials

Your information will be encrypted.