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Client Information and Intake Form
425 S. Orleans Ave.Tampa, Florida 33606

Jenine LaCoe, MA, LMHC, DCC, CCM
jeninelacoe@gmail.com
813-220-1001
#MH18998
NPI 1396321618
CAQH 15141442
EIN 87-1733666
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Today's Date *
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Name *
Email *
Phone Number ( VM messages okay? ) *
Date of Birth *
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Sex
Clear selection
Street Address, City, State and Zip Code
Referral Source
Presenting Problem and History related to concerns
Family Dynamics
Family Illness History
Previous Therapy (Past Diagnosis)
Medications (Past and Current)
Alcohol or Drug Use
Sleep and Eating Habits
Sex Life
Employment and Education History
Legal Involvement
Who provides you with support and encouragement?
Do you enjoy how you spend your day? What is your favorite thing that you do each day, and what part of your day is unpleasant?
Can you describe your intention or goal or what changes or habits you would like to make in your life?
Please use this space to write about anything you feel is important for me to know, If you prefer not to write about it, I will be happy to hear you tell me any other information when we meet
If using United, Cigna or Aetna Healthcare, please provide the following Information: Insured's I.D. Number and Group Number *
ACKNOWLEDGING BELOW INDICATES THAT YOU HAVE READ AND UNDERSTOOD THE PSYCHOTHERAPIST- PATIENT AGREEMENT, THAT YOU HAVE HAD A CHANCE TO DISCUSS ANY CONCERNS OR QUESTIONS WITH ELIZABETH MAHANEY OR JENINE LACOE AND AGREE TO THE TERMS AND ALSO, SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE READ THE HIPAA NOTICE FORM. BOTH FORMS AVAILABLE ON WEBSITE: WWW.SOUTHTAMPACOUNSELOR.COM *
FINANCIAL AGREEMENT Credit Card Number on File: Jenine LaCoe respects your time and sets aside time to see you when you make an appointment with her. A session usually lasts 60 minutes and payment is due at the time of treatment. It is important that clients respect the therapist’s time as well. Clients wishing to cancel or change an appointment must give the counselor 24-hours notice. In most cases, the therapist will be able to accommodate another client if such notice is given. To impress upon clients the importance of giving advance notice when canceling appointments, the counselor requires a credit card number and information on file. If a client no-shows or cancels at the last minute or without giving 24 hours notice so that the slot may not be taken by someone else who is waiting for therapeutic care, the credit card will be charged for the full cost of the missed appointment. In addition, if payment is made by check and a check is returned, the owed amount will be charged to the credit card plus a $30 returned check fee.Once again, be warned – clients who miss appointments or cancel without 24 hours notice will be charged for a full missed appointment based on the hourly rate. Please provide credit card information here. Jenine LaCoe will be very respectful of this information and your rights to privacy: *
Name on Credit Card *
Credit Card Number *
Expiration Date *
Security Code *
I understand that my credit card may be billed for a missed appointment if I fail to give 24 hours notice. If you are sick and must miss an appointment, or experience a dire personal emergency, the counselor may forfeit the missed appointment fee, at her discretion, on a case-by-case basis. *
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