South Tampa Therapy Initial Intake
SOUTH TAMPA THERAPY & MEDIATION
Client Information Form and Initial Interview
Elizabeth Mahaney , LMHC, MFT, NCC, Ph.D
M.A., RMHCI Intern:__________________
#MH-10069 NPI# 1609248145
ElizabethMahaney@msn.com
Email address *
425 S. Orleans Ave.Tampa, Florida 33606 813-240-3237
Name
Your answer
Today's Date
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Age and D.O.B.
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Sex
If Minor Adult/ Guardian Relation
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Street Address City State Zip
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Phone Numbers (If couple, BOTH) Ok to leave a message?
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Email Address (If couple, BOTH email addresses)
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Referral Source
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Family Members/ Children/ Significant Others Age Relation
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Presenting Problem
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History Related to Problem
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Family Composition and Dynamics
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Education Past and Current
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Employment Past and Current
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Medications Past and Current
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Previous Therapy (Past Diagnosis)
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Family Illness History
Your answer
Eating Habits
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Sleep Habits
Your answer
Sex Life
Your answer
Alcohol or Drug Use
Your answer
Legal Involvement
Your answer
Who provides you with support and encouragement?
Your answer
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?
Your answer
Can you describe your specific intentions and goals or what changes you would like to make happen in your life?
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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.
Your answer
If using United Healthcare, please provide the following Information: Insured's I.D. Number, Group Number, Patient's First, Last Name and Date of Birth
Your answer
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 THE SUPERVISED INTERN 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 *
Required
Dr. Mahaney is a Qualified Clinical Supervisor for B.A., M.A., Internship/ Practicum/ Field Study Students & Intern Candidates for State Licensure. Will you allow an intern to shadow or co-counsel your sessions? http://floridasmentalhealthprofessions.gov/licensing/qualified-supervisor/State Approved
FINANCIAL AGREEMENT Credit Card Number on File: Elizabeth Mahaney 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. Elizabeth Mahaney will be very respectful of this information and your rights to privacy: *
Name On Credit Card *
Your answer
Credit Card Number *
Your answer
Zip Code *
Your answer
Expiration Date *
Your answer
Security Code # (3 numbers on back of card) *
Your answer
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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