ADULT Counseling Intake Form

Patient Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Sex*

MaleFemale

Email*

example@example.com

Home Phone*

Area CodePhone Number

Cell Phone*

Area CodePhone Number

How may we contact you?*

EmailPhoneTextUSPS

Marital Status

Employment

Primary Care Provider*

May your therapist contact your primary care provider or psychiatrist to coordinate care if they feel it is in your best interest.*

YesNo

Referral Name

First NameLast Name

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Relationship

You are responsible for paying your unmet deductible amount or co-pay at the time of your appointment. If you have a secondary insurance, as a courtesy, we will file the claim with your secondary insurance after your primary insurance has been paid. Secondary insurances may have different reimbursement rates and do not always cover some procedures. If your secondary insurance pays your co-pay, we will refund the co-pay amount paid by your secondary insurance within 7 working days of receipt of the secondary payment.

Primary Insurance Carrier*

Policy Number

Secondary Insurance (If applicable)

Subscriber Name

First NameLast Name

Subscriber Date of Birth

Date

Subscriber Relationship to Patient

Group Number

Please check all the apply

Do you use tobacco?

Do you use alcohol?

Caffeine use?

Have you been convicted of drug related charges?

YesNo

Please explain the circumstances

Are you currently taking prescription medication?*

YesNo

Please list medications:

Family history

Why you are seeking treatment?*

What do you expect from this counselling?*

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?*

YesNo

Therapist Name

First NameLast Name

Reason for seeking help

Average hours of sleep per night

Please describe any other experiences you have had problems with

Additional comments or concerns

This is a professional counseling facility. We offer professional counseling to individuals struggling with a variety of issues. Professional counselors, social workers, and therapists that are licensed by the State of Georgia perform our counseling. Our counselors have earned a master’s degree (or higher) in counseling, psychology or a closely related field from an accredited institution. Therapy can last from a few weeks to several months. Most people find therapy very helpful, however, depending on the nature of your difficulty, you might also experience uncomfortable emotions such as anger, fear, and frustration during the course of your counseling. While your counselor cannot remove these feelings from you, they will help you work through them, or find an alternative counselor. You are free to discontinue therapy at any time. Most people remain in therapy until they feel that they have learned better methods of thinking, feeling, and/or acting regarding their difficulties. Occasionally, the therapist elect to discontinue therapy. This usually happens when they feel that no substantial progress is being made or other factors are interfering with their ability to help you. If therapy ends prematurely, we will help you find qualified help elsewhere. Under normal circumstances everything you discuss with your counselor will be held in strict confidence. However, you should be aware that there are some situations in which your counselor may be required by law to report information to the proper authorities without your permission or knowledge. These situations include but may not be limited to a client’s indication of bodily harm to others, suicidal intentions, and reasonable suspicion of child or elder abuse or neglect. Your counselor may also disclose information in response to a subpoena issued by a court of law. *Your signature below indicates that the information you have provided above is truthful.

Date

Signature*

HERITAGE COUNSELING, INC - ADULT

Emergency Contact Information

Insurance Information

Medical History

Mental Health History

COURT RELATED INFORMATION