Confidential Client History Form Confidential Client History Form Please be aware that unencrypted electronic communications are at risk of being intercepted and/or read by unintended parties. If you prefer, you can download a copy of this form from my website and return it to my office via regular postal mail instead. Name Date Home Phone Work Phone Cell Phone Email Address Skype Address City State Zip Date of birth Age Gender In a relationship with life partner? # of children Name of person who referred you to me Contacting you: In an effort to protect your privacy, when contacting you I will identify myself by my name only and not by my position as a psychotherapist. That stated: May I contact you at work if necessary? Yes No May I leave a message on your voicemail at home? Yes No May I leave a message on your voicemail at work? Yes No May I leave a message on your cell phone voicemail? Yes No May I email you? Yes No Please comment on any restrictions to the above Emergency Information: In case of emergency, please contact: Name Relationship to client Telephone (Cell) Telephone (Home) Telephone (Work) Address (City, State, Zip) Medical Information: Physician name Physician phone number Psychiatrist name (if applicable) Psychiatrist phone number (if applicable) Current Medications Are you currently undergoing medical treatment? Yes No How are your sleeping patterns? Allergies: Employment Information: Place of employment Position Telephone Intake Information: Reason you are coming: Have you been in therapy before? How did it go for you? Please give a brief account of your current living situation (who you live with, etc, and any information you think is relevant) Have you been experiencing suicidal thoughts or impulses? If so, please describe: Please tell me anything else you think is important for me to know about your situation before we meet. Weekday times between 7:00 AM and 8:00 PM when you are available for appointments: (Appointments after 4:00 PM are by far the most requested times. These slots are very rarely available. If you are able to come during daytime hours, there is a much greater chance we will be able to meet.) Monday: Tuesday Wednesday Thursday Friday Skype: In special circumstances, video sessions via Skype are possible. Generally, Skype sessions are only an option when agreed upon in advance, for planned for use in long-distance situations, i.e. Skype is not an option for sessions that had originally been scheduled to take place in the office, but that then can’t be kept for one reason or another. It’s also important to note that, at this time, insurance does not cover sessions conducted via Skype. Method of Payment (select one) Cash Check Insurance *If you wish to use insurance, I will provide you with receipts coded to insurance industry specifications. You can submit these receipts to your insurance company for reimbursement. Since I work exclusively for you, I don’t take direct payment from insurance companies. I am an “out-of-network” provider. This enables me to deliver a higher quality of care, with individualized attention, and complete confidentiality. For more information about payment and insurance, see the “Fees” section of this website. ** Clients may also use Venmo (an online payment system similar to PayPal) Sign here (typed name serves as electronic signature) Date of signing
