Adult 1

Revised

12/11/19

CLIENT INFORMATION INTAKE FORM

***This information will be kept completely confidential.***

(PLEASE READ THROUGH THOROUGHLY AND PRINT CLEARLY)

I welcome you to my faith-based, independent private practice. It is my goal to work collaboratively

with you using evidence-based methods to address the concerns you are experiencing. As your

counselor my goal is to form a mutually respectful relationship with you in order to assist you in

finding healthy solutions for your concerns. Although my counseling practice is independent of the

Roman Catholic Diocese of Corpus Christi, any other Catholic Diocese, or any individual Roman

Catholic parish, I strive to serve clients by providing evidenced-based mental health services that are

consistent with all teachings of the Catholic Church. You may opt to receive counseling that is not

from a faith-based perspective. If you opt to receive counseling that is not from a faith-based

perspective by signing this consent you acknowledge that I do not separate my faith from who I am as

a counselor.

Please read all information provided in this packet, and if you have any questions, discuss them with

me. Your signature at the bottom of this sheet signifies that you have read, understand, and agree to

abide by all policies.

Today’s Date: ____________________

Please initial next to one of the following:

____ I acknowledge that my counselor is Catholic, adheres to all teachings of the Catholic Church,

and I wish to receive counseling from a faith-based perspective.

____ I acknowledge that my counselor is Catholic, adheres to all teachings of the Catholic Church,

and I DO NOT wish to receive counseling from a faith-based perspective.

Name: ___________________________________________ Birthdate:____________________

Street Address:______________________________________________________________________

______________________________________________________________________

Mailing Address:____________________________________________________________________

______________________________________________________________________

Home Phone ____________________________ Work Phone ______________________________

Best Number Where a Message can be Left ___________________________

Highest Level of Education/Earned Degree(s): _____________________________________________

Place/Type of Employment_____________________________________ How long? _____________

Adult 2

Revised

12/11/19

If unemployed, how long: ______________ What type of work did you do? _____________________

MARITAL STATUS

1. Single 2. Cohabitating 3. Married 4. Divorced 5. Widowed

If cohabitating, married, divorced, or widowed, length of time: ________________________________

Spouse/Partner Name_________________________Spouse/Partner Occupation_______________________

CHILDREN

NAME BIRTHDATE GENDER

Religious Affiliation (Self):

Religious Affiliation (Spouse/Partner):

Do you and/or your family currently attend church? Yes _____ No_____

Parish/House of Worship:

Frequency of church attendance:

Please describe the role that faith/religion plays in your life:

When was your last full physical exam?

Primary Care Physician Name & Phone #:

Please list any physical conditions or medical diagnoses you may have:

Sleeping issues? Y N How many hours of sleep do you get each evening? _________________

Adult 3

Revised

12/11/19

Medication Dosage Frequency Prescribing Physician

Family history of mental health and/or addiction related disorders: (include parents, grandparents,

aunts, uncles, etc.)

Do you have a personal history of substance or alcohol use and/or abuse and/or other addictions (e.g.,

gambling, shopping, etc.), Yes No

Have you ever had concern about your eating habits and/or been diagnosed with an eating disorder

(compulsive overeating, binge eating, anorexia, bulimia)? Yes No

If yes, please indicate which and provide more specifics including any history of treatment and/or

participation in support groups:

Do you have current thoughts of suicide? Yes No If so, do you have a plan? Yes No

Have you ever had thoughts about suicide? Yes No

Have you ever attempted suicide? Yes No If yes, how many times? __________

Have you ever been hospitalized for psychiatric reasons? Yes No

If yes, what were the circumstances?

Please include dates: _________________________________________________________________

How do you spend time relaxing?

Adult 4

Revised

12/11/19

Have you ever been in counseling before? Y N For how long? ______

Was it helpful? Yes No

Please explain:

Reason(s) for seeking counseling at this time:

Please check any of the following areas of concern:

___Headaches ___Nervousness ___Dizziness ___Fainting Spells

___Shyness ___Stomach Trouble ___Relaxation ___Stress

___Anxiety ___Fatigue ___Legal Matters ___Self Control

___No Appetite ___Anger ___Memory ___Making Decisions

___Insomnia ___Nightmares ___Separation ___Energy

___Inferiority ___Take Sedatives ___Drug Use ___Loneliness

___Bowel Troubles ___Marriage ___Use Alcohol ___Allergies

___Suicidal ___Sexual Problems ___Work ___Under eating

___Overeating ___Home Conditions ___Friends ___Concentration

___Temper ___Ambition ___Divorce ___My Thoughts

___Parenthood ___Health Problems ___Age ___Finances

___My appearance ___Future ___Sexual Abuse ___Children

___Career Choices ___Weight ___Unhappiness ___Depression

___Mood Swings ____Fears ___Self-esteem ___Physical Abuse

Circle check everything you have experienced in the past two years:

___ Death of a spouse/partner ___ Marriage Problems ___ Divorce

___ Death of a family member ___ Legal Problems ___ Major illness/injury of relative

___ Major illness/injury of self ___ Job dissatisfaction ___ Bad break up

___ Financial issues ___ Loss of job Other:

___ Move to another city or state ___ Family Issues (with children/parents/in-laws)

Adult 5

Revised

12/11/19

Therapist/Client Agreement & Consent for Treatment

The nature of the therapeutic relationship and counseling process is such that there is a beginning and an end. This means that my

counselor will assist me to meet the goals on which I would like to work. My counselor views this process as a collaborative one

where clients are the experts on their lives, and the counselor is a companion and guide who works with clients to assist them in

writing and rewriting their stories. I acknowledge that I am voluntarily participating in counseling/therapy. I understand that

counseling/therapy is a process and that the issues I have struggled with will not be instantly resolved.

I recognize that I play a vital role in my treatment. I take responsibility in my treatment and in my treatment process which includes

attending counseling sessions as regularly as I can and completing work assigned for my time outside of sessions. I accept that I may

discuss things that are difficult to discuss and recognize that this is important to my healing process. I understand that therapy is not a

process in which my therapist takes sides, gives me advice, or solves my problems. I understand that therapy is a process that can

provide insight and help me build the skills necessary for me to resolve many of my own issues. Once I have met my goals, my

counselor will assist me in transitioning out of counseling with the option to return to counseling in the future should I need to do so.

If my counselor deems that I have met my goals and begins the termination process, this is not a personal rejection or done out of

malice. My counselor has a duty to make decisions out of her best clinical judgment and for my own welfare. It is agreed that either

my counselor or I may discontinue this evaluation and treatment at any time and that I am free to accept or reject the treatment

provided.

I understand that I have a right to confidentiality based on HIPAA. I understand that what is said in my therapy sessions will not be

revealed to others. I understand that my therapist cannot provide information about me or acknowledge that I am her client without

expressed written consent from me. The only exception to my privacy is in situations where disclosure is required by law:

Threats of harm towards myself or another

If I give reasonable concern regarding the suspected or actual abuse of a child

If I give reasonable concern regarding the suspected or actual abuse of an elderly individual or a disabled/incompetent

individual

If I see my therapist in public, I acknowledge that she will only acknowledge me if I acknowledge her first. This is to maintain my

privacy according to HIPAA standards. I understand that my therapist does not maintain friendships or other personal relationships

with clients outside of counseling sessions including relationships on social media.

I understand that if I am using insurance to cover the cost of my therapy my therapist will provide information to my insurance

company for billing purposes or as requested by my insurance company. If a judge subpoenas my records, I understand my therapist

must comply. If I request a copy of my records, I must pay a fee of $25 for the first 20 pages, $0.50 per page thereafter, and actual

shipping costs if records are sent through the mail. This fee plus shipping must be paid before I can receive a copy of my record.

I understand that payment of services is due at the end of each session, unless otherwise agreed upon by my insurance company or

EAP provider. I also understand that if I miss my appointment without at least 24-hour notice, I will be charged $40, and my sessions

will not resume until this fee has been paid. If my insurance company denies payment of my services for any reason and will not

resolve this issue, my counselor reserves the right to charge the card on file for the balance of the session. I understand that

there is no fee if I decide to cancel my services entirely. I understand that my counselor utilizes Square Appointments to provide me

with a convenient way to schedule my appointments. I understand that my counselor requires each client, including me, to provide a

credit or debit card number to schedule an appointment and that I need to keep a credit or debit card number on file in Square

Appointments. If I do not have a credit or debit card on file in Square Appointments, I acknowledge that my appointments will not be

scheduled until I provide such information.

I understand that my counselor may consult with other professionals in her field in order to provide the best care possible to me while

maintaining my confidentiality. I acknowledge that this is a standard practice in the field of mental health. In the event that my

counselor becomes incapacitated or deceased, she has completed a plan of practice, and I may receive notification from one of her

designated colleagues as well as referrals to other mental health professionals in order to maintain a continuity of care. This consent

for treatment is a living document. My counselor may update it at any time and ask me to sign the updated consent for treatment.

The address for the Texas State Board of Examiners of Professional Counselors is MC 1982, P. O. Box 141369, Austin, TX 78714-

1369, phone 800-942-5540. I have the right to contact the licensing board should I have any complaints to make against my

counselor.

By signing this consent, I agree to and will abide by all of the above.

Client Signature Counselor Signature Date

Adult 6

Revised

12/11/19

Individual, Marriage, and Family Therapy

Electronic Communication Consent

Electronic communication such as text messaging, video phone calls, and e-mail are efficient methods

of communicating but are not as secure as other forms of communication. Text messages and e-mails

have a risk of being intercepted by others and/or may not be received due to unforeseen technical

difficulties. While this is never anticipated, it is possible.

Please sign below if you understand the risks involved with electronic communication and would like

to communicate electronically via email, text, and/or video phone calls.

Please specify which types of communication you would like to utilize in order for your counselor to

communicate with you:

______Text

______ Phone

______ Video Phone (Facetime, Skype, etc.)

______ Email – Please provide your email address: ________________________________________

_______ Other (please specify)

Client Signature Date

Adult 7

Revised

12/11/19

Individual, Marriage, and Family Therapy

FEE SCHEDULE FOR SERVICES PROVIDED

Any therapy or counseling services for insured clients will adhere to the contracts between the provider

and insurance company. If insurance coverage is lost, client(s) do not have insurance, or client(s)

chooses to receive counseling through private pay, client(s) can continue or receive services at a cost

determined based on income (45-50 minutes in length, not to exceed 60 minutes). For any additional

participants in the counseling session, a $10 fee per person will be charged above the base session fee.

Services that go over the one hour mark are billed $20 for each additional 15 minutes.

Additional fees are can be incurred if additional services are needed that are not covered by a client’s

insurance plan. Additional services and resulting fees are as follows:

Phone consultations – May be between client or an individual in which the client expresses a desire

that I consult with on their behalf (such as lawyers or other medical professionals).

0-5 Minute Phone call – No Charge

Up to 45 minute Phone Consultation: $65

Face-to-face meeting up to 60 minutes with travel:

$90 plus standard mileage reimbursement rate.

Costs for obtaining copies of records:

$25 for first 20 pages and $0.50 a page thereafter per client.

Cost for filling out forms on your behalf:

$25 initial fee for up to five pages

$10 for each additional page above five pages

Cost for writing letters on your behalf:

$50 for the first page

$25 for each additional page

If I appear at court on your behalf the fee is $700 even if the court hearing is delayed. The cost will

apply to each day that I appear at court on your behalf. If the court hearing is in a different county, the

standard IRS mileage reimbursement rate will apply.

By signing below, I agree to adhere to the above listed fees. All fees (co-pays and/or other fees

outlined) are to be paid at the end of the counseling session.

Client Signature Date

Adult 8

Revised

12/11/19

Individual, Marriage, and Family Therapy

FEE SCHEDULE FOR SERVICES PROVIDED

Any therapy or counseling services for insured clients will adhere to the contracts between the provider

and insurance company. If insurance coverage is lost, client(s) do not have insurance, or client(s)

chooses to receive counseling through private pay, client(s) can continue or receive services at a cost

determined based on income (45-50 minutes in length, not to exceed 60 minutes). For any additional

participants in the counseling session, a $10 fee per person will be charged above the base session fee.

Services that go over the one hour mark are billed $20 for each additional 15 minutes.

Additional fees are can be incurred if additional services are needed that are not covered by a client’s

insurance plan. Additional services and resulting fees are as follows:

Phone consultations – May be between client or an individual in which the client expresses a desire

that I consult with on their behalf (e.g., lawyers, school personnel, or other medical professionals).

0-5 Minute Phone call – No Charge

Up to 45 minute Phone Consultation: $65

Face-to-face meeting up to 60 minutes with travel:

$90 plus standard mileage reimbursement rate.

Costs for obtaining copies of records:

$25 for first 20 pages and $0.50 a page thereafter per client.

Cost for filling out forms on your behalf:

$25 initial fee for up to five pages

$10 for each additional page above five pages

Cost for writing letters on your behalf:

$50 for the first page

$25 for each additional page

If I appear at court on your behalf the fee is $700 even if the court hearing is delayed. The cost will

apply to each day that I appear at court on your behalf. If the court hearing is in a different county, the

standard IRS mileage reimbursement rate will apply.

The address for the Texas State Board of Examiners of Professional Counselors is MC 1982, P. O. Box

141369, Austin, TX 78714-1369, phone 800-942-5540.

Adult 9

Revised

12/11/19

PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9)

Over the last 2 weeks, how often have you been

bothered by any of the following problems? (Circle the

number that represents your answer.) Not at all Several

days

More

than half

the days

Nearly

every

day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you are a failure or

have let yourself or your family down 0 1 2 3

7. Trouble concentrating on things, such as reading the

newspaper or watching television 0 1 2 3

8. Moving or speaking so slowly that other people could

have noticed? Or the opposite — being so fidgety or

restless that you have been moving around a lot more than

usual

0 1 2 3

9. Thoughts that you would be better off dead or of hurting

yourself in some way 0 1 2 3

FOR OFFICE CODING 0 + ______ + ______ + ______ =

Total Score: ______

If you checked off any problems, how difficult have these problems made it for you to do your work, take

care of things at home, or get along with other people?

Not difficult

at all Somewhat

difficult Very

difficult Extremely

difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

Adult 10

Revised

12/11/19

GAD-7 Anxiety

FOR OFFICE USE: Column totals: ___ + ___ + ___ + ___ =

Total Score _____

If you checked off any problems, how difficult have these problems made it for you to do your work, take

care of things at home, or get along with other people?

Not difficult

at all

Somewhat

difficult

Very

difficult

Extremely

difficult

Over the last 2 weeks, how often have you

been bothered by the following problems?

(Please circle the number that corresponds to your answer)

Not

at all

Several

days

More than

half the

days

Nearly

every day

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful

might happen

0 1 2 3