Intake Information Form (with legal agreements)

Please answer questions for identified client except in cases of main contact information, in which case we would need the information of the legal guardian who will be making decisions regarding payment and scheduling. Once we receive this information, we will be sending you a PDF copy to e-sign, through our Therapy Portal system, stating that all the below information is accurate to the best of your knowledge.
Email address *
You will need the following handy in order to complete this form in one sitting: Insurance information (if using), including the subscriber/member's address and date of birth; Primary Care Physician (if you have one).
Full Name of identified client *
Address *
Main contact person (i.e. legal guardian)
Please mention name and relationship to client here
Main mobile phone number
Please mention if this is the number of the identified client or the main contact person
Home number
Date of birth of identified client *
Reason for coming to counseling
Scheduling issues: best days and times
Teletherapy Preferences *
Most of our therapists are counseling remotely. Please indicate your preferences regarding remote counseling (also known as teletherapy). If you are allowing teletherapy as an option, please read the Informed Consent for Teletherapy below and check the appropriate box afterward. You will be required to e-sign a copy of this form after we receive and process it.
Required
Informed Consent for Teletherapy
By checking the "I have read and acknowledge the terms of teletherapy" below, I understand, acknowledge and agree that I am signing this Consent electronically, that I have reviewed, understand and accept the risks and benefits of telehealth services as described below, and that I wish to receive those services.
If I am agreeing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services.
1. By acknowledging below, I agree to receive teletherapy services. Teletherapy involves the delivery of counseling services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my CCA Counselor and I will be able to see and/or speak with each other from remote locations.
2. I understand that if I am seeing my CCA counselor in-person on a regular basis, I may be asked to transition to teletherapy if (i) I am experiencing symptoms of illness and want to continue to have counseling; (ii) my CCA counselor is experiencing symptoms of illness but is willing to continue counseling remotely; and/or (iii) I need to stay home to care for family members due to illness and/or care facility closures. I also understand that though I have been offered this transition, I have the right to refuse teletherapy, and that if I do, I will need to reschedule my appointment for another day.
3. I understand and agree to the following about teletherapy:
• I will not be in the same location or room as my CCA counselor.
• My CCA Counselor must be licensed/certified in the state in which I am receiving services. I will report my location accurately at the beginning of each session.
• Potential benefits of teletherapy (which are not guaranteed or assured) include: (i) access to counseling services if I am unable to travel to my CCA counselor’s office; (ii) during the COVID-19 pandemic, reduced exposure to patients, staff and other individuals at a physical location; (iii) less need for the counselor/patient to wear mask, therefore allowing better communication.
• Potential negatives of teletherapy include: (i) Less opportunity for my CCA counselor to read body language in communication; (ii) restriction of options for engagement with youth through play therapy and games; (iii) restrictions and/or limitations in insurance coverage.
• I may discuss these pros and cons with my CCA counselor. I understand that I have the right to withdraw this consent for teletherapy services or end the teletherapy session at any time.
• I understand that the level of care provided by my CCA counselor is the same level of care that is available to me through an in-person counseling visit. However, if my CCA counselor believes I would be better served by face-to-face services, I will have the option of transitioning to face-to-face counseling and referred to a counselor who offers it within CCA if necessary.
• I understand that there are unique risks specific to teletherapy services including, but not limited to, the possibility of disruption, distortion or unauthorized access during transmission of Protected Health Information (PHI) or Personally Identifiable Information (PII) due to internet/electronic/technical failures beyond the control of CCA. The Zoom video conferencing platform used by CCA is HIPAA compliant for privacy/security, and I will visit it for instructions prior to initiating teletherapy. I understand that I am solely responsible for the privacy and confidentiality in my surrounding environment while engaged in teletherapy and will exercise appropriate privacy measures.
By checking "I have read and acknowledge the terms of teletherapy" below, you are stating that you have read the above-mentioned Informed Consent for Teletherapy and agree to its terms. *
Preferences for counselor
Clear selection
Spouse/Children/Others in the home
Please mention their relationship to the identified client (i.e John Smith--brother). Enter new line per person mentioned.
Under any civil protection order?
Clear selection
Date of Marriage
Previous Divorce
Clear selection
Highest education level completed
Employer (or school)
Occupation
How did you hear about Christian Counseling Associates Inc.?
Next
Never submit passwords through Google Forms.
This form was created inside of Christian Counseling Associates. Report Abuse