New Client Registration Form

Full Name*

Date of Birth:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

How did you hear about us?*

Personally referred by:*

Who is your emergency contact?

Emergency Contact phone number:

Please enter a valid phone number.

Are you comfortable with virtual sessions via zoom?

What prompted you to seek counseling at this time?

Relationship Status:

Current Occupation:

Are you interested in psychedelic integration?

UnsureCurrently InterestedInterested in the futureNo Interest

What types of mental health services have you had previously? (check all that apply)

Are you experiencing any chronic pain?

Are you taking any opiates or pain medications at this time?

Please list any family history of mental health (including addictions) and their relation to you:

Are you currently experiencing overwhelming sadness, grief or depression?

Are you having any anxiety, panic attacks or phobias?

How many alcoholic drinks do you have in a week?

Are you taking any prescription medications?

Please list any medical ailments or physical disorders:

Please give a brief description of what you want to discuss in your first session: (optional)

CONSENT FOR TREATMENT

and LIMITS OF LIABILITY

Limits of Services and Assumption of Risks

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress you are feeling, improve relationships, and/or resolve other specific issues. However, these improvements cannot be guaranteed for any condition due to the many variables that affect psychological events and personal functioning.

Limits of Confidentiality

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent. The following is a list of exceptions:

1) Duty to Warn and Protect- If you discolse a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan or threat to harm another person, the therapist is required to warn the possible victim and notify legal authorities.

2) Abuse of Children and Vulnerable Adults- If you disclose, or it is suspected that there is abuse or harmful neglect of children or vulnerable adults, the therapist must report this information to the appropriate state agency and/or legal authorities.

3) Prenatal Exposure to Controlled Substances- Therapists must report any admitted prenatal exposure of controlled substances that could be harmful to the mother or the child.

4) Insurance Providers- Insurance companies and other third-party payers are given informtiaon that they request regarding services to the client.

The type of information that may be requested includes: types of services, dates of service, diagnosis, treatment plan, description of impairment, progress in therapy, case notes, and summaries.

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

Signature*

Date*

Date

Please verify that you are human*

My Services

53min Individual Psychotherapy Product Image

53min Individual Psychotherapy Private in-Office or Zoom Session

$200.00

2 Session Psychotherapy Bundle Product Image

2 Session Psychotherapy Bundle2 1hr Sessions

$360.00

Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Dr. Laurie Maddox