Client Intake Form

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell phone*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Employer/School*
Emergency Contact Person*
Relation*
Phone Number*

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Guarantor (Person responsible for any balance after payment at the time of the appointment and insurance payment, if applicable)*

PatientSpouse (adult patient)Parent (minor patient)
Name of primary insurance
Name of secondary insurance, if applicable
Subscriber ID
Group Number
Plan Name

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
How did you find me?
Reason for the appointment? *
Previous treatment (Please list therapists, psychiatrists, psychiatric hospitalizations and approximate dates. Include substance abuse treatment)*
Current medication (Prescribed and over the counter)*
Primary Care Physician (Name, Address, Phone, Fax) *
Medical and neurological history (Please list any significant illnesses or injuries)

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Substance abuse history: Alcohol How much do you drink?
Do you have, or have you had, a problem with alcohol?
Have family or friends ever been concerned about your use of alcohol?
Do you smoke and if so, how much?
Do you or have you used any street drugs? (Please state what and how much)
Do you, or have you ever used more than your prescribed medication?
Where were you born and where were you raised?
Please list any problems, complications or delays in development from pre-birth through early childhood.
Please list any problems you had slash or have in school.
Your highest level of education.
Please list your current or most recent employment.
Please list any employment problems that may be related to mental health concerns.

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Are you single, married or in a long term relationship, divorced, or widowed?
If married, when?
Spouse's/Partner's name
Do you have any problems/concerns in your marital or long-term relationship?
Do you or your spouse have any children? (Names and ages)
Do you have any significant problems or concerns about your children?
If separated or divorced, when did this occur?
What are the primary reasons for separation and divorce?
What is the custody agreement?
Are there problems with aggression or violence in your household or with a significant other?

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Have you ever experienced physical, emotional or sexual abuse?
Have you ever received treatment for this issue?
Have you ever witnessed or experienced any other traumatic event?
Have you ever had any legal problems?

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Acknowledgement of Receipt of Professional Disclosure Statement and Informed Consent

SIGNATURE BELOW INDICATES THAT YOU HAVE REVIEWED THE AGREEMENT TITLED “PROFESSIONAL DISCLOSURE STATEMENT” AND YOU AGREE TO ITS TERMS. THIS DOCUMENT INFORMS YOU ABOUT MY BACKGROUND, DISCLOSES MY PHILOSOPHY OF THERAPY, AND INFORMS YOU OF POLICIES, PROCEDURES, LEGAL AND ETHICAL CONSIDERATIONS. THE LATEST PROFESSIONAL DISCLOSURE STATEMENT IS AVAILABLE ON MY WEBSITE UNDER “DISCLOSURE STATEMENT”.
Signature (electronic)*

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Acknowledgement of Receipt of Privacy Notice

I have carefully reviewed and understand the Notice of Privacy Policy. The latest version of this policy is available on my website under “Privacy Statement”. The Notice of Privacy Policy describes how my medical information may be used and disclosed and how I can get access to this information. At any time I may request further explanation regarding the use and disclosure of my protected health information.
Signature (electronic)*

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Name of primary insurance company:
Name of secondary insurance company, if applicable:
Please be sure to provide your insurance card at our first session. If you do not have your insurance card, you will need to pay in full for the appointment. A refund will be issued if the insurance is successfully billed at a later date.

I authorize the release of all medical records to my insurance company. I further authorize insurance payments to be made directly to Anne M. Coleman, LCSW. I understand co-payments, deductibles, self-pay charges are due at time of service regardless of whether the guarantor is present. Charges for services provided between appointments are due at the next appointment or when billed.
Signature (electronic)*

Client Intake Form

Please Complete This Intake Prior to Your First Appointment with Me.
Financial Policy

For managing account information and for convenience I am able to provide a monthly statement of charges. If you choose to use your insurance, I am glad to file the proper paperwork. You will be responsible for the remaining balance not covered by insurance – such as copays, co-insurance and sometimes deductibles. All patients must provide a valid credit card to guarantee payment for services. The guarantor may also elect to authorize that the weekly charges for my services be automatically posted to a designated credit card at the end of each week.

Credit Card information is required
Should be Empty: