Intake Questionnaire and Forms
Brief questionnaire to provide basic contact and initial therapeutic information
Moscow Counseling LLC | 828 S. Washington St., Suite C | Moscow, ID 83843
Client's First Name
Client's Last Name
Client's Date of Birth
City, State, Zip
Call and or Text Allowed for this Number?
Do Not Call
Do Not Text
Contact via Email Allowed?
Name of Emergency Contact
Relation of Emergency Contact
Emergency Contact Phone Number
Client's Gender Identity / Expression
Client's Sexual / Affectual Orientation
Client's Preferred Pronouns
Client's Religion / Spiritual Beliefs
Briefly describe the purpose for seeking counseling.
Please check any of the following symptoms you are currently experiencing:
Feeling easily annoyed
Sleep disruptions | Feeling excessively tired
Lack of interests or motivation
Feeling awkward in social situations
Episodes of panic
Disordered Eating Habits
How long have you been experiencing mental health concerns?
Have you ever been in counseling before?
Please list any medications or supplements you are currently taking.
How did you hear about Moscow Counseling?
Friend / Relative
Moscow Chamber of Commerce
Physician / Practitioner
Informed Consent for Counseling
The counseling relationship is very unique. It is highly personal and private while also including necessary healthy boundaries and therapeutic expectations. Given this, it is important for us to have a clear understanding about how the counseling relationship will work.
THE THERAPEUTIC PROCESS
The outcome of your treatment is largely influenced on a client's willingness to engage in this process. At times the process may result in emotional discomfort. For example, remembering unpleasant events and becoming aware of feelings attached to those events can bring about strong emotional responses such as anger, depression, anxiety, etc.
There is a potential for increased frequency and intensity of presenting symptoms during treatment. I will do my best to understand and support my clients through the counseling process. However, I cannot promise that circumstances will change or improve to one's expectations.
The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named individuals or entities. For clients under the age of eighteen, parents have a right to receive periodic progress updates. However, underage clients have the right to privacy. Should any client under the age of eighteen disclose information that pertain to the limits of confidentiality, parents will be notified immediately.
LIMITATIONS OF CONFIDENTIALITY
There are limitations of confidentiality that include:
If a client threatens or attempts to commit suicide or otherwise conduct themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If I have reasonable suspicion that a client or other named person is the perpetrator or actual victim of neglect, physical, emotional or sexual abuse of children, elderly, or other vulnerable populations.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for my clients. Information about my clients may be shared in this context without using any identifying information.
APPOINTMENTS, CANCELLATIONS, AND TARDINESS
The standard session time is 50 minutes. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
Please remember to cancel or reschedule 24 hours in advance. The cancellation policy is necessary because a time commitment is made to you and is held exclusively for you.
**Cancellations not received at least 24 hours in advance of your scheduled session start time or being absent from your scheduled session without notice will be subject to a full charge of treatment fees.**
*If you are late for a session, you will lose some of that session time. Tardiness or online counseling technical difficulties will NOT extend your scheduled session end time.*
COMMUNICATION BETWEEN SESSIONS
If you need to contact me between sessions, I will attempt to return messages in a timely manner, but I cannot guarantee immediate response and request that you do not use these methods of communication to request assistance for emergencies.
If a true emergency situation arises, please call 911 or any local emergency room.
I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy.
Electronic communication includes, but is not limited to, telephone communication, the Internet, facsimile machines, and e-mail. If others have access to your electronic equipment, I cannot ensure the confidentiality of any form of communication through electronic means, including messages sent to you.
The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effective. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT CLIENTS:
I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
For my use in treating you.
For my use in defending myself in legal proceedings instituted by you.
For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
Required by law and the use or disclosure is limited to the requirements of such law.
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
Required to help avert a serious threat to the health and safety of others.
II. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
III. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record. I will provide you with a summary within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
Agreement to Consent, Policies, and Practices
BY CHECKING THIS BOX AND TYPING MY NAME BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Client/Legal Guardian Electronic Signature (Type Full Legal Name)
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