New Client Intake Form Revised Sept 2022

Responsible Party Information

The information in this section should be the for the person financially responsible for the Patient.
Responsible Party Legal Name*

First NameMiddle NameLast NameSuffix
Responsible Party Physical Address*

Street Address

Unit, Apt #, etc.

CityState

Zip CodeCountry
Responsible Party Email Address
example@example.com
Responsible Party Phone Number*
Please enter a valid phone number.
Responsible Party Date of Birth*

MonthDayYear
Responsible Party Gender

FemaleMale
Responsible Party Social Security Number

Primary Insurance Policy Information

If the information given is inaccurate, or the policy has termed, the patient or responsible party will be responsible for cost of visit.
Primary Insurance Carrier*
Insurance Carrier Name
Primary Insurance Policy ID*
e.g. VMAH98765432, 987654321, W1234567
Sponsor SSN or Patient DBN*
Please note that if the client is the Active Duty Prime member, a PCM referral or MOS authorization is required. If neither are obtained, client will be charged a Self Pay rate.
Tricare Coverage (Pick 2!)
Is the Patient the Subscriber/Policy Holder/Sponsor?*

YesNo
Subscriber Legal Name*

First NameMiddle NameLast NameSuffix
Subscriber Physical Address*

Street Address

Unit, Apt #, etc.

CityState

Zip CodeCountry
Subscriber Email Address
example@example.com
Subscriber Phone Number
Please enter a valid phone number.
Subscriber Date of Birth*

MonthDayYear
Subscriber Gender*

FemaleMale
Subscriber Social Security Number
Insurance Card (Front)

Cancelof
Insurance Card (Back)

Cancelof
Does the Patient have Secondary Insurance?*

YesNo

Secondary Insurance Policy Information

If the information given is inaccurate, or the policy has termed, the patient or responsible party will be responsible for cost of visit.
Secondary Insurance Carrier*
Insurance Carrier Name
Secondary Insurance Policy ID*
e.g. VMAH98765432, 987654321, W1234567
Sponsor SSN or Patient DBN*
Please note that if the client is the Active Duty member, a PCM referral or MOS authorization is required. If neither are obtained, client will be charged a Self Pay rate.
Tricare Coverage
Is the Patient the Subscriber/Policy Holder/Sponsor for the Secondary Policy?*

YesNo
Subscriber Legal Name*

First NameMiddle NameLast NameSuffix
Subscriber Physical Address*

Street Address

Unit, Apt #, etc.

CityState

Zip CodeCountry
Subscriber Email Address
example@example.com
Subscriber Phone Number
Please enter a valid phone number.
Subscriber Date of Birth*

MonthDayYear
Subscriber Gender

FemaleMale
Subscriber Social Security Number
Insurance Card (Front)

Cancelof
Insurance Card (Back)

Cancelof

Self Pay

	Age
1st Child
2nd Child
3rd Child
4th Child
5+ (add age separated by comma)

Parent Coordination Information
Other Party/Parent of Child(ren) Legal Name*

First NameMiddle NameLast NameSuffix
Other Party/Parent of Child(ren) Date of Birth*

MonthDayYear
Marriage Date

MonthDayYear
Date Separated

MonthDayYear
Divorce Date

MonthDayYear

Identity of the Children

	Name	Age	DOB
1
2
3
4
5
6

I need to add more children

Parent Coordination Agreement
Non-Disparaging Clause
Signature*

Clear
Today's Date*

MonthDayYear
Fees & Billing
General Terms & Conditions
Term, Rule Adjustments, & Court Order Supersedes Statements
I have read and understood the above Parenting Coordination Agreement and agree to abide by its terms:
Signature*

Clear
Today's Date*

MonthDayYear

Medication Management
Signature*

Clear
Today's Date*

MonthDayYear
Signature*

Clear
Today's Date*

MonthDayYear

Psychological Evaluation

Notice of Privacy Policies & Communications
My signature acknowledges that I have read, understand, and agree to all parts of the Privacy Policies & Communications of Pattison Professional Counseling Center.
Signature*

Clear
Today's Date*

MonthDayYear
Date

Financial Policy
My signature acknowledges that I have read, understand, and agree to all parts of the financial policy of Pattison Professional Counseling Center. I also understand that my account could be turned over to a collection agency if it becomes delinquent.
Signature*

Clear
Today's Date*

MonthDayYear
Date

Client Rights
Client Responsibilities
I have read this list of rights and responsibilities or had them read to me. I understand and agree to them.
Signature*

Clear
Today's Date*

MonthDayYear
Date

Informed Consent for Telehealth Services
I hereby attest by signature that I have read, understood, and agree to the terms of this document.
Signature*

Clear
Today's Date*

MonthDayYear
Date

Notice of Protected Health Information & Communications
Phone Number for text/phone message to be left:*
Please enter a valid phone number.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

	Medication	Dosage	Frequency	Start Date	End Date
1
2
3
4
5
6

	Date	Facility	Inpatient or Outpatient	Diagnosis
1
2
3
4
5

	Yes	No	Age at 1st Use	Frequency	Date Last Used
Marijuana
Inhalants
Cocaine
Crack
Heroin
Methadone
Tranquilizers
Valium
Librium
Quaaludes
Pills
Dust
LSD/PCP
Black Tar
Prescription
OTC
Other

	Yes	No	How Often	Comments
Slapped
Punched
Choked
Pulled Hair
Pushed
Restrained
Kicked
Used Weapon
Thrown Things
Other

	Yes	No
Threatened to take the children away from your partner?
Threatened suicide?
Threatened to injure your partner or children?
Threatened to hurt your partner's friends or family?
Threatened to destroy property?
Threatened to leave your partner?
Insist your partner take part in illegal activities?
Threatened your partner if they didn't drop charges against you?

Patient Demographic Information Section

Emergency Contact Information

Brief Questionnaire

Responsible Party Information

Primary Insurance Policy Information

Secondary Insurance Policy Information

Authorization Information

Self Pay

Clinical Information

Medical History

Psychological Symptoms

Mental Health History

Family History

Educational History

Goals for Treatment

Parent Coordination Information

Parent Coordination Agreement

Non-Disparaging Clause

Fees & Billing

General Terms & Conditions

Term, Rule Adjustments, & Court Order Supersedes Statements

Substance Abuse / Alcohol Screening

Drug History

Analysis of Current Problems

Domestic Violence Intervention Program

Medication Management

Psychological Evaluation

Notice of Privacy Policies & Communications

Financial Policy

Client Rights

Client Responsibilities

Informed Consent for Telehealth Services

Notice of Protected Health Information & Communications

	Yes	No
Made your partner afraid by looks, actions, or gestures?
Yelled, pounded your fist, or punched walls?
Smashed things in front of your partner?
Driven recklessly with your partner in the vehicle?
Hit or mistreated pets?

	Yes	No
Put down your partner or called them names?
Told your partner not to feel a certain feeling (sad, hurt, angry)?
Humiliated your partner?

	Yes	No
Kept your partner from going to work, school, or out with friends?
Listened to your partner's phone calls?
Followed your partner around?
Told your partner that they are not spending enough time at home?
Asked your partner what was said and done while they were out?

	Yes	No
Made light of the abuse and did not take your partner's concerns seriously?
Told others that the abuse didn't happen?
Told your partner that they were the cause of the abuse?
Blamed alcohol or drug use for the cause of the abuse?

	Yes	No
Tried to make your partner feel guilty about the children?
Used the children to relay messages?
Used visitation to harass your partner?
Threatened to take the children away?