Mt. Hebron Counseling Services

Intake Form

Todays Date

First name *

Last name

Date of Birth

Address *

City *

State *

Zip *

Home Phone

Cell #

Work #

Marital Status *

Sex *

Ethnicity

Employer

Job Title

IF MINOR: Responsible Person

IF MINOR: School

IF MINOR: Grade

Please list other household members:

Name

Relationship

Date of Birth

In case of Emergency

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship *

Insurance

Insurance Provider Name

ID #

Policy Holder's Name

Policy Holder's Date of Birth

Phone #

Employer

Pre-Authorization #

EMPLOYEE ASSISTANCE PROGRAM (EAP) (In most cases, the client has to call the EAP program to activate benefits)

EAP Provider

Insured Person

Employer

EAP Authorization #

PRIMARY CARE PROVIDER

Physician's Name

City

Medications you are currently taking

REFERRAL SOURCE

Name of person who referred you

Relationship (Physician, Minister, Friend, Family, etc.)

Why are you coming to counseling and what do you hope to gain from it? *

Please read the New Client Information, Professional Disclosure Statement Act, Your Rights under HIPAA, Consent to Treatment and acknowledge by writing your name in the "Signed By" field below.

Consent to Treatment

I have read the following documents:
- New Client Information
- Professional Disclosure Statement
- HIPAA Client Rights Statement
I am aware that I may terminate treatment with my provider at any time.
I authorize the release of treatment information to my insurance company upon request, and as needed for the purpose of filing insurance claims.
I authorize Mt. Hebron Counseling Services to receive payments directly from my Insurance company, or Employee Assistance Program.
I understand that I am responsible for any portion of my fee for therapy which is not covered by insurance.
Legal Policy - I understand and agree that all information, communication, observation and opinions deriving from my treatment will be considered private and confidential between me and my therapist. My therapist is a licensed professional and trained to work with me on resolution of my presenting issues and does not claim to be a legal expert witness of any type. My therapist feels that litigation is by nature an adversarial process and is incompatible with the goals of therapy. My therapist does not wish to be involved in litigation of any type, and my acknowledgement of these terms indicates my understanding of this.
Our Clinicians are committed to spending your time actively engaged in therapy. Therefore, any out-of-agency paperwork including disability, legal or FMLA, etc. should be directed to your Primary Care Provider.
Not showing up for a scheduled appointment, without a prior cancellation of 24 HOURS, will result in my being charged a $40.00 NO SHOW FEE.
Unless otherwise indicated, I understand my case will be considered inactive if I have not had any contact with you after 60 days.

I agree to the above listed items *

I AGREE TO THE ABOVE

Electronic Signature *

Date

Electronic Signature - Additional Attendee

Date

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