New Client Intake Form
Client Intake Information (please print, complete, and bring with you to the first session)
Personal History
Today’s Date____________ Birthdate_______________ Referred by_____________________
Name (please print)______________________________________________________________
Address_______________________________________________________________________
Phone________________________________ OK to leave message?______________________
Email_______________________________________ OK to leave email?___________________
Employer___________________________________ Occupation__________________________
Family History
Marital status:
Single ____________ Married ______________ How many times? _________________
Spouse’s Name___________________________________ Spouse’s Birthdate_______________
Widowed: Date of spouse’s Death___________________________________________________
Divorced: Date of divorce _________________________________________________________
Separated: Date of separation _____________________________________________________
Living with Significant Other/Roommate ___________ Name ______________________________
Children’s names and ages ________________________________________________________
Siblings’ Names and ages _________________________________________________________
Parents’ names______________________________________ Still living?___________________
Medical History
Primary care physician_______________________________________ Phone________________
Address _______________________________________________________________________
Current medication and dosages __________________________________________________
Current non-prescription meds and usage____________________________________________
Date of last medical exam____________________ Presenting problem ____________________
List any physical problems________________________________________________________
Do (or did) your parents use drugs/alcohol?___________________________________________
Which parent? __________________ Which drugs/alcohol? _____________________________
Do you use drugs/alcohol? _________ Type and frequency: _____________________________
Frequency of recreational computer and/or video game use: _____________________________
Have you been to counseling before? _____________ With whom? _______________________
Would you like me to coordinate with the previous counselor? _____________________________
What brings you to counseling now? ________________________________________________
What else would you like me to know? ______________________________________________
What would you like to achieve from counseling? _______________________________________
Insurance Information
Name of Insurance Company ___________________________ Phone _____________________
Address of Insurance Company ____________________________________________________
Name of Insured _____________________________________ Birthdate___________________
Insurance ID___________________________________________________________________
Group number _________________________________________________________________
Office Use Only
Intake Date_______________________ Case termination Date __________________________
Diagnosis: Axis I _______________ Axis II ___________________ Axis III _________________
Axis IV ________________________ Axis IV (current GAF) _______ (highest in last year) ______
THERAPEUTIC CONTRACT
The Therapy Process--Participating in therapy can result in a number of benefits to you, including a better understanding of your personal goals and values, improved interpersonal relationships, and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part and may result in your experiencing considerable discomfort. Change will sometimes be easy and swift, but more often it will be slow and frustrating. Remembering and resolving significant life events in therapy can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, and other individuals can also lead to discomfort and may result in changes that were not originally intended. As part of my therapeutic process, I use several techniques including cognitive behavioral therapy, with visualization, relaxation, desensitization, and Thought Field Therapy when indicated, and when appropriate, Eriksonian hypnosis. Couples and family therapy use a systems approach. Areas of specialty include post traumatic stress disorder and related symptoms such as depression and anxiety; bariatric pre and post surgery adjustment; sexual abuse and associated dysfunctions; codependent and victim patterns; phobia and stress disorders; and disassociative identity disorder.
Client’s Rights--You have the right to a confidential relationship with me. Within certain legal limits (see #3 below), information revealed by you during the course of therapy will be kept completely confidential and will not be revealed to any person without your written permission.
1. You have the right to know the content of your records at any time and I have the right to provide you with the complete records or a summary of their content.
2. If you ask me, I can release any part of your records on file to any person you specify. I will tell you when you make your request whether or not I think releasing that information to that agency or person might be harmful to you.
3. Under certain legally defined situations, I have the duty to reveal information you tell me during the course of therapy to other persons without your written consent. I am not required to inform you of my actions if this occurs. These legally defined situations include:
a. Revealing to me active child abuse or neglect. If an alleged perpetrator is in contact with minors and there is a reasonable suspicion that he/she may still be abusing minors. Active physical or sexual abuse of a dependent adult or an elder is taking place.
b. If you seriously threaten harm or death to another person, I am required to warn the intended victim and notify the appropriate law enforcement agencies.
c. If you are in court-ordered therapy or are being tested by order of the court, the results of the treatment or tests ordered must be revealed to that court.
d. If a court of law issues a legitimate subpoena, I am required by law to provide the information
specifically described in that subpoena.
e. If you are in a lawsuit claiming emotional harm, the opposing side may subpoena your therapy records.
4. You have the right to ask questions about any of the procedures used in the course of your therapy.
5. The use of email may be an appropriate way to transmit information to me for the next session or for me to send you appointment or therapeutic information. Although every effort to keep emails confidential is taken, the confidentiality of emails is not guaranteed. If you would like to use email as a way to communicate between sessions, please initial here. _____________ yes, I would like to have the choice to use email.
6. Should you choose not to enter therapy with me, I will provide you with names of other qualified professionals whose services you might prefer.
7. You have the right to terminate therapy with me at any time without any financial, legal, or moral obligations other than those you’ve already incurred. I have the right to terminate therapy with you under the following conditions:
a. When I believe that therapy is no longer beneficial to you.
b. When I believe that another professional will better serve you.
c. When you have not paid for the last two sessions, unless we have made other arrangements.
d. When you have failed to show up for your last two therapy sessions without a 24-hour notice.
e. If I determine during the first three sessions that I cannot help you, I will assist you in finding
someone qualified to do so. If I have written consent, I will provide that professional with
information they request.
f. When you fail to cooperate with the proposed treatment.
If any of these situations apply, I will send you a certified letter to your address of record to inform you of my decision and I will give you the names of several therapists for your future counseling needs. As life can bring unexpected circumstance, should I be unable to continue your therapy, my assistant, in consultation with my office colleagues, will contact you with other therapy options.
Education and Experience--I have an M.S. in Counseling Psychology from Eastern Washington University (1988), a B.S. in Child Development and Family Relationships from Brigham Young University (1976), I am a Certified EMDR Practitioner, a Certified Hypnotherapist, have Level I and II certification in Thought Field Therapy, and have taken the training to be a mediator and an Allied Professional in Collaborative Law.
I have been in private practice at Northwest Family Counseling since 1991. Previously, I worked at Good Samaritan Mental Health Center in Puyallup for five years as an individual and family therapist. I have worked as a Guardian ad Litem, and have worked with domestic violence victims at the Domestic Abuse Women's Network (DAWN) in Kent.
Fees and Length of Therapy--I agree to enter therapy with Wendy Rawlings MS LMHC. The average length of treatment at her office is six months and understand that my treatment may be more or less than the six month average. The treatment plan will reference my expected length of treatment and frequency of sessions.
I agree to pay the standard fee of $________ for each completed fifty-minute session, or release the needed information to bill my insurance company . I will make payment or co-payment by cash or check at the time of my appointment, unless other arrangements have been made. I understand that I can leave therapy at any time and that I have no financial, legal, or moral obligation to complete the maximum number of sessions I miss without providing 24-hour notice, and telephone time as outlined in the Office Policies Section.
Date___________________ Client’s Signature____________________________________
Therapist’s Signature_________________________________
Consent for Treatment-- I__________________________________________authorize and request that Wendy Rawlings MS LMHC carry out psychological assessments, diagnostic procedures, and/or treatment which not or during the course of my care as a client are advisable.
I understand that the purpose of any procedure will be explained to me and be subject to my agreement. I have read and fully understand this Consent for Treatment form.
Date___________________ Client’s Signature______________________________________
Date___________________ Therapist’s Signature___________________________________
OFFICE POLICIES
Payment for Service: You are expected to pay for services at the time they are rendered unless other arrangements have been made. Please notify me if any problem arises regarding your ability to make timely payment.
Insurance: I will bill insurance for you if you have insurance. You will need to make a co-pay at each session. You agree to pay any insurance deductibles or any legitimate service the insurance will not cover.
Cancellation: Since an appointment reserves time specifically for you, a minimum of 24 hours notice is required for rescheduling or cancellation of an appointment. The full fee will be charged for missed sessions without such notification. Most insurance companies do not reimburse for sessions missed.
Office Hours: My office hours are from 10 AM to 6 PM Tuesday through Thursday in Federal Way and every other Friday in Tacoma. If you need to contact me between sessions, please leave a message and I will return your call.
Telephone time: After 10 minutes of telephone time, you will be charged at your regular fee.
Sessions Longer than 55 minutes: Sessions that go beyond fifty-five minutes will be prorated to the nearest quarter hour, unless we have made prior arrangements.
Emergency Procedure: An emergency is an unexpected event that required immediate attention and can be a threat to your health. If an emergency situation arises, please state this when you leave our message and I will return your call as soon as possible. If I have not called you back within 60 minutes and the emergency persists and the emergency requires it, please call your physician or the crisis line at 206-461-3222.
I have read and understand these office policies.
_______________________________________________________________________________
Client’s printed name Date Client’s Signature
_______________________________________________________________________________
Therapist’s printed name Date Therapist’s Signature
Personal History
Today’s Date____________ Birthdate_______________ Referred by_____________________
Name (please print)______________________________________________________________
Address_______________________________________________________________________
Phone________________________________ OK to leave message?______________________
Email_______________________________________ OK to leave email?___________________
Employer___________________________________ Occupation__________________________
Family History
Marital status:
Single ____________ Married ______________ How many times? _________________
Spouse’s Name___________________________________ Spouse’s Birthdate_______________
Widowed: Date of spouse’s Death___________________________________________________
Divorced: Date of divorce _________________________________________________________
Separated: Date of separation _____________________________________________________
Living with Significant Other/Roommate ___________ Name ______________________________
Children’s names and ages ________________________________________________________
Siblings’ Names and ages _________________________________________________________
Parents’ names______________________________________ Still living?___________________
Medical History
Primary care physician_______________________________________ Phone________________
Address _______________________________________________________________________
Current medication and dosages __________________________________________________
Current non-prescription meds and usage____________________________________________
Date of last medical exam____________________ Presenting problem ____________________
List any physical problems________________________________________________________
Do (or did) your parents use drugs/alcohol?___________________________________________
Which parent? __________________ Which drugs/alcohol? _____________________________
Do you use drugs/alcohol? _________ Type and frequency: _____________________________
Frequency of recreational computer and/or video game use: _____________________________
Have you been to counseling before? _____________ With whom? _______________________
Would you like me to coordinate with the previous counselor? _____________________________
What brings you to counseling now? ________________________________________________
What else would you like me to know? ______________________________________________
What would you like to achieve from counseling? _______________________________________
Insurance Information
Name of Insurance Company ___________________________ Phone _____________________
Address of Insurance Company ____________________________________________________
Name of Insured _____________________________________ Birthdate___________________
Insurance ID___________________________________________________________________
Group number _________________________________________________________________
Office Use Only
Intake Date_______________________ Case termination Date __________________________
Diagnosis: Axis I _______________ Axis II ___________________ Axis III _________________
Axis IV ________________________ Axis IV (current GAF) _______ (highest in last year) ______
THERAPEUTIC CONTRACT
The Therapy Process--Participating in therapy can result in a number of benefits to you, including a better understanding of your personal goals and values, improved interpersonal relationships, and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part and may result in your experiencing considerable discomfort. Change will sometimes be easy and swift, but more often it will be slow and frustrating. Remembering and resolving significant life events in therapy can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, and other individuals can also lead to discomfort and may result in changes that were not originally intended. As part of my therapeutic process, I use several techniques including cognitive behavioral therapy, with visualization, relaxation, desensitization, and Thought Field Therapy when indicated, and when appropriate, Eriksonian hypnosis. Couples and family therapy use a systems approach. Areas of specialty include post traumatic stress disorder and related symptoms such as depression and anxiety; bariatric pre and post surgery adjustment; sexual abuse and associated dysfunctions; codependent and victim patterns; phobia and stress disorders; and disassociative identity disorder.
Client’s Rights--You have the right to a confidential relationship with me. Within certain legal limits (see #3 below), information revealed by you during the course of therapy will be kept completely confidential and will not be revealed to any person without your written permission.
1. You have the right to know the content of your records at any time and I have the right to provide you with the complete records or a summary of their content.
2. If you ask me, I can release any part of your records on file to any person you specify. I will tell you when you make your request whether or not I think releasing that information to that agency or person might be harmful to you.
3. Under certain legally defined situations, I have the duty to reveal information you tell me during the course of therapy to other persons without your written consent. I am not required to inform you of my actions if this occurs. These legally defined situations include:
a. Revealing to me active child abuse or neglect. If an alleged perpetrator is in contact with minors and there is a reasonable suspicion that he/she may still be abusing minors. Active physical or sexual abuse of a dependent adult or an elder is taking place.
b. If you seriously threaten harm or death to another person, I am required to warn the intended victim and notify the appropriate law enforcement agencies.
c. If you are in court-ordered therapy or are being tested by order of the court, the results of the treatment or tests ordered must be revealed to that court.
d. If a court of law issues a legitimate subpoena, I am required by law to provide the information
specifically described in that subpoena.
e. If you are in a lawsuit claiming emotional harm, the opposing side may subpoena your therapy records.
4. You have the right to ask questions about any of the procedures used in the course of your therapy.
5. The use of email may be an appropriate way to transmit information to me for the next session or for me to send you appointment or therapeutic information. Although every effort to keep emails confidential is taken, the confidentiality of emails is not guaranteed. If you would like to use email as a way to communicate between sessions, please initial here. _____________ yes, I would like to have the choice to use email.
6. Should you choose not to enter therapy with me, I will provide you with names of other qualified professionals whose services you might prefer.
7. You have the right to terminate therapy with me at any time without any financial, legal, or moral obligations other than those you’ve already incurred. I have the right to terminate therapy with you under the following conditions:
a. When I believe that therapy is no longer beneficial to you.
b. When I believe that another professional will better serve you.
c. When you have not paid for the last two sessions, unless we have made other arrangements.
d. When you have failed to show up for your last two therapy sessions without a 24-hour notice.
e. If I determine during the first three sessions that I cannot help you, I will assist you in finding
someone qualified to do so. If I have written consent, I will provide that professional with
information they request.
f. When you fail to cooperate with the proposed treatment.
If any of these situations apply, I will send you a certified letter to your address of record to inform you of my decision and I will give you the names of several therapists for your future counseling needs. As life can bring unexpected circumstance, should I be unable to continue your therapy, my assistant, in consultation with my office colleagues, will contact you with other therapy options.
Education and Experience--I have an M.S. in Counseling Psychology from Eastern Washington University (1988), a B.S. in Child Development and Family Relationships from Brigham Young University (1976), I am a Certified EMDR Practitioner, a Certified Hypnotherapist, have Level I and II certification in Thought Field Therapy, and have taken the training to be a mediator and an Allied Professional in Collaborative Law.
I have been in private practice at Northwest Family Counseling since 1991. Previously, I worked at Good Samaritan Mental Health Center in Puyallup for five years as an individual and family therapist. I have worked as a Guardian ad Litem, and have worked with domestic violence victims at the Domestic Abuse Women's Network (DAWN) in Kent.
Fees and Length of Therapy--I agree to enter therapy with Wendy Rawlings MS LMHC. The average length of treatment at her office is six months and understand that my treatment may be more or less than the six month average. The treatment plan will reference my expected length of treatment and frequency of sessions.
I agree to pay the standard fee of $________ for each completed fifty-minute session, or release the needed information to bill my insurance company . I will make payment or co-payment by cash or check at the time of my appointment, unless other arrangements have been made. I understand that I can leave therapy at any time and that I have no financial, legal, or moral obligation to complete the maximum number of sessions I miss without providing 24-hour notice, and telephone time as outlined in the Office Policies Section.
Date___________________ Client’s Signature____________________________________
Therapist’s Signature_________________________________
Consent for Treatment-- I__________________________________________authorize and request that Wendy Rawlings MS LMHC carry out psychological assessments, diagnostic procedures, and/or treatment which not or during the course of my care as a client are advisable.
I understand that the purpose of any procedure will be explained to me and be subject to my agreement. I have read and fully understand this Consent for Treatment form.
Date___________________ Client’s Signature______________________________________
Date___________________ Therapist’s Signature___________________________________
OFFICE POLICIES
Payment for Service: You are expected to pay for services at the time they are rendered unless other arrangements have been made. Please notify me if any problem arises regarding your ability to make timely payment.
Insurance: I will bill insurance for you if you have insurance. You will need to make a co-pay at each session. You agree to pay any insurance deductibles or any legitimate service the insurance will not cover.
Cancellation: Since an appointment reserves time specifically for you, a minimum of 24 hours notice is required for rescheduling or cancellation of an appointment. The full fee will be charged for missed sessions without such notification. Most insurance companies do not reimburse for sessions missed.
Office Hours: My office hours are from 10 AM to 6 PM Tuesday through Thursday in Federal Way and every other Friday in Tacoma. If you need to contact me between sessions, please leave a message and I will return your call.
Telephone time: After 10 minutes of telephone time, you will be charged at your regular fee.
Sessions Longer than 55 minutes: Sessions that go beyond fifty-five minutes will be prorated to the nearest quarter hour, unless we have made prior arrangements.
Emergency Procedure: An emergency is an unexpected event that required immediate attention and can be a threat to your health. If an emergency situation arises, please state this when you leave our message and I will return your call as soon as possible. If I have not called you back within 60 minutes and the emergency persists and the emergency requires it, please call your physician or the crisis line at 206-461-3222.
I have read and understand these office policies.
_______________________________________________________________________________
Client’s printed name Date Client’s Signature
_______________________________________________________________________________
Therapist’s printed name Date Therapist’s Signature
