New Client Registration Form/Face Sheet-Sally Dorpfeld, LMHC

Sally Dorpfeld, LMHC, MCAP, ICADC

Licensed Mental Health Counselor
New Client Registration

Please fill in the form below with the client information
Date Today*

MonthDayYear
DateHourMinutesAM/PM Option
Name*

First NameMiddle NameLast Name
Take Photo of ID Card Front (State/License) *if client is a minor provide adult ID
Take Photo of ID Card Back *if client is a minor provide adult ID
E-mail (If minor use parent/guardian email)*
Gender of client*
Please Select
Client Date of Birth*

MonthDayYear
Age of Client
Grade (If Student)
*Do not need to fill out if you are not a student
Contact Number:*

Area CodePhone Number
2nd Contact Number:

Area CodePhone Number
Relationship Status
Client Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:*

First NameLast Name
Phone Number for Emergency Contact*

Area CodePhone Number
Relationship to Client*
Email for Emergency contact
example@example.com
Taking any medications, currently?*

YesNo
If yes, please list it here
Name of Primary Insured*
Date of Birth of Primary Insured*

MonthDayYear
Date
Name of Insurance Carrier and ID#*
If you do not have insurance, or have already provided this in Tava/Headway/Grow already there is no need to provide it here. Just write N/A.
Group#*
If you do not have insurance, or have already provided this in Tava/Headway/Grow already there is no need to provide it here. Just write N/A.
Insurance Carrier Contact information (Phone, Address, Website for submitting claims. Usually found on back of insurance ID Card*
If you do not have insurance, or have already provided this in Tava/Headway/Grow already there is no need to provide it here. Write N/A.
Take Photo of Insurance ID card front
Take Photo of Insurance ID card back
Please check the items that you believe are affecting you

Alcohol or drug problemsAnger or hostile feelingsAnxiety, nervousness, fearsSadness or DepressionEating or appetite problemsFamily issuesProcrastinationPhysical distressRelationship/marital concernsSexual concernsShynessTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStressSleep disorderSelf-controlSelf-esteem or confidenceWork or career concernsThoughts of self-harmThoughts of harm to another personThoughts of suicide
Fees / 24 hour Cancellation Policy

The fees for my services are as follows:

$125.00 for a 60 min. Individual Session

$90.00 for a 45 min. Individual Session

$30.00 for each 15 mi. added on to a Session

If you cancel an appointment with less than 24 hours notice, or fail to show up, you will be charged a late Cancellation Fee. If you cancel with less than a full 24-hour notice, I won't be able to fill that time slot, and I'll lose an entire hour from my work schedule, you will be charged 60% of the session fee (125.00 Session Fee = $75.00 Charge). If you are a NO SHOW for the appointment scheduled, you will be charged 100% of the session fee (125.00 Session Fee = $125.00 Charge).
Should be Empty:

Sally Dorpfeld, LMHC, MCAP, ICADC

New Client Registration