To enable us to provide you with the best care possible be sure to fill out all pages front and back



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New Client Packet Checklist:

Welcome to Life in Balance Center. The following list will help us provide you better service. This packet takes about 45 to 60 minutes to complete. Please provide us with as much information as possible, as this will help us to file your insurance.


To enable us to provide you with the best care possible be sure to fill out all pages front and back.



  • Insurance Card Please bring with you to your first appointment. We must have this to copy and put in your file.

  • Driver’s License or Photo ID to be copied for records.

  • Any additional Medical Records or notes from previous practitioners.

  • HIPPA Form has been signed.

  • Informed Consent signed and initialed where indicted.

  • Clients Rights & Responsibilities signed and initialed where indicted.

  • Client Registration filled out completely. Under this if you are not the policy holder of the insurance please indicate the insured’s Date of Birth and social security number. This now required when we submit a claim. If you do not have this information, we cannot bill your insurance. We must have this information to prevent you from being held responsible for charges that your insurance will cover.

  • Client Intake Form please fill this out as completely as you can. This will help your practitioner understand more about your visit. Be sure to sign this form.

  • Brief Medical History please fill this out completely.

  • Communication Sheet this is the last page of the packet, please fill in your name and date of birth, the name of the practitioner that you will be working with at Life in Balance on the line next to clinician’s name, the name and demographic information of the person or entity that you wish to share your information with, please wait to sign and date this sheet until you check in with our receptionist so that they can witness your signature.

  • Please Review Check each page that it has been signed and initialed.

Thank you for your cooperation and patience in filling out these forms to help us better understand your needs. This insures we can bill your insurance correctly. We hope to continue to serve all your needs and appreciate the opportunity to serve you.





CLIENT REGISTRATION
Date of Birth ____/____/______ Today’s Date: ____/____/______
Client’sFullName:_______________________________SociaLSecurity#:______________

Home Address: ____________________________________________________________ City: ___________________________State: _________ Zip________________ Mailing Address (if different) _______________________________________________

Do we have authorization to send mail to the address listed above? yes no

Phone:(H)________________ __(O)___________________

Client Employer:_____________________________ Occupation: _____________________

Male/Female Single/Married/Separated/Divorced Race:________________

Employed/Retired/Unemployed/Disabled Are you a Student? Yes No

Family Physician: ________________________________ Phone #:______________________

Referred by: _________________________________________________________________

Emergency Contact Name: _________________________________ Phone#:______________

INSURED/RESPONSIBLE PARTY INFORMATION

Please complete this section all information is required in order to bill insurance, missing information may result in inability to bill insurance and leave you liable for payment.

Full Name of Policy Holder: ________________________________________________

Relationship to Client: ______________________ Policy Holders Date of Birth____________

Home Address: _____________________________ Phone #: __________________________

Occupation:_____________________________________________________________

Employer and Address: _________________________________ Phone #: ________________

Policy Holders SS#:_____________________________,

Single/Married Employed/Unemployed/Retired

Clients Primary Ins. Co. __________________________ ID#: _________________________
Group#: _____________________________________


Clients Secondary Ins. Co._________________________ ID#:________________________

Group#:________________________________

INFORMED CONSENT


Thank you for choosing the Life in Balance Counseling & Wellness Center. Today’s initial appointment will take approximately 50 minutes. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. All of the clinicians in our practice have earned a graduate degree (Masters or Doctorate) from an accredited University. All Life in Balance Clinicians are licensed to practice in the state of Virginia. Life in Balance also employs resident clinicians who have completed a graduate degree and are pursuing licensure under direct supervision of a licensed clinician. The clinical supervisors name and credentials may be obtained upon request. Our clinicians only practice within their scope of training and experience. In the course of our training and previous employment we have had experience in treating a wide variety of individuals including children, adolescents, adults, individuals, couples, families, and groups. Your counselor will have his/her own primary specialty areas of expertise. Treatment practices, philosophy and plan limitations and risks will be discussed with you today. Laura Rumfeldt M.S., is a Counseling Resident in training under the weekly supervision of Angela McGoldrick, LPC. If you should have any questions, she can be contacted through our front desk staff.

OUR PRACTICE CONSISTS OF THE FOLLOWING CLINICIANS:

Angela McGoldrick, LPC ☼ Alan Forrest, LPC, LMFT ☼ Dr. Mary M. Amtower, LPC

☼ Barrie Bondurant, Ph.D., LPC ,☼Cynthia Blevins, LPC ☼ Jennifer Mercier, LPC

☼Laura Rumfeldt, M.S. – Resident Counselor ☼ Sarah L. Hastings, Ph.D


CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information shared with consultants, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information you and/or family members report about physical or sexual abuse, neglect or exploitation of a child, elderly or disabled person (By Virginia State Law, we are obligated to report this to the Department of Social Services Adult or Child Protective Services.), d) where you sign a release of information to have specific information shared and e) if you provide information that informs me that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and h) or when required by law. In the unlikely event that your clinician is unable to provide ongoing services another clinician within the group practice will provide those services and will maintain your records for a period of 7 years. Please contact the executive director Angela McGoldrick, LPC for any questions pertaining to this. If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for those services. You may also contact ACCESS Services for Emergencies at 540-961-8400. Our Clinicians will follow those emergency services with standard counseling and support to the client or the client's family.
FINANCIAL/INSURANCE ISSUES: As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If the balance is not paid after 45 days, any unpaid balance will be charged 1.5% interest a month (18% APR). In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to the Life in Balance Counseling & Wellness Center. Returned checks will carry a $30.00 NON-INSURANCE BILLABLE fee and are expected to be paid in full prior to your next appointment.
__________________________________________ _________________ Client Signature Date

Fees for Service

Initial Assessment & Diagnosis (45-55 minutes) $115.00

Clinical Therapy Session (50 minutes) $95.00

Session by phone (30 minutes) $95.00

Short Clinical Session (25-30 minutes) $47.50

Group Therapy Session (50 minutes) $40.00

Appearance in Court (per hr.) $500 + $100.00

Records and Document Review ($30 min.) $95.00 per hour Written Correspondence (depending on type) $50.00 per page



CANCELATION POLICY

If you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed $50.00 for the missed appointment this charge CANNOT be billed to insurance. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.



COORDINATION OF TREAMENT: It is important that all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. If you prefer to decline consent no information will be shared, however we do need your physicians name and demographic information for insurance billing.



____You may inform my physician(s) ____I decline to inform my physician
Physician’s Name:_________________________________________________

Clinic___________________________________________________________

Address:_________________________________________________________

Phone:___________________________________

Client Signature Date
NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: I/We have read and received a copy of the, Notice of Privacy Practices and Client Rights document.
OFFICE HOURS Our office hours are Monday – Thursday 9am-6pm and Fridays 9:30-4:30pm. You may reach our office by phone at 540-381-6215 to schedule an appointment. If we are unavailable you may leave a message on our confidential voice mail box and someone will return your call as soon as possible.

Client Signature Date


AUTHORIZATION

I authorize treatment deemed necessary by Life in Balance Counseling & Wellness Center Practitioners. I authorize Life in Balance Counseling & Wellness to release to my health plan any and all information which she deems necessary regarding my care and treatment to insure prompt payment of all charges for services provided. I hereby assign the payment for all insurance benefits to Life in Balance Counseling & Wellness for any and all charges incurred in connection with services provided to me. I also consent to a copy of this authorization and assignment being used in place of the original.
I understand fully that I remain responsible to pay Life in Balance Counseling & Wellness Center for all charges not paid by either my insurance companies and/or employer, subject to the rules of any federal or state health insurance program such as Medicaid, or to other contractual provisions that may limit a patient’s responsibility to pay for medical costs and services. Payment shall be due at the time of the appointment or within thirty days of receipt of a statement.
METHOD OF PAYMENT

All payments and/or co-payments are due at the time of each appointment. Our office accepts personal checks, cash, Visa, and MasterCard. A returned check fee of $35.00 will be charged.

If we receive more than one returned check from an individual we reserve the right to refuse future payment by check.



NO SHOW POLICY

Please contact our office within 24 hours if you are not able to make your appointment. If you do not show for a scheduled appointment a NO SHOW FEE of $50.00 will be charged for the cost of the missed appointment. This cost is not covered by insurance and is your responsibility and must be paid in full before your next appointment. If a second appointment is missed without canceling with a 24 hour notice, all future appointments will be canceled until you speak with your counselor concerning this matter. If a third appointment is missed your counselor may not be willing to reschedule with you depending on your situation.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THIS INFORMATION.

__________________________________________ _________________

Client Signature Date

UNDERSTANDING PSYCHOTHERAPY
It is important for you to understand what counseling is about and what you may expect during therapy. Please read this material carefully and ask the therapist to explain anything that is unclear to you.
What are Counseling and Psychotherapy?

“Counseling” and “Psychotherapy”, or simply “therapy”, are words for the same process which is: using proven methods to assist people in changing how they feel and how they behave. Legitimate therapy is practiced by professionals Licensed (or license eligible under supervision) by the state in the areas of Clinical Social Work, Professional Counseling, Psychology, or Psychiatry.



The Risks of Counseling:

Research has shown that competent therapy provided by trained and licensed professionals is helpful to most people. At the same time, therapy is not guaranteed to result in a successful outcome every time for everyone. It is important that you understand this before you invest time and money in counseling. The greatest risk of counseling is that it may not, by itself, resolve your problem or concern. Unexpected emotional strain, stress, and life changes may happen during therapy. Other people in your life may not react to changes you make during therapy in the way you would like for them to respond.



How does therapy work?

Therapy at Life In Balance will involve several steps. Therapy sessions are usually 45 to50 minutes in length, and are typically held one time per week.

First, your counselor will listen to the concerns that you brought to counseling. He/she will get to know you and how you view your life and yourself. You will probably understand your situation better as you and your counselor talk. After you and your counselor explore your concerns, you will choose specific goals and objectives for therapy. Next, you and your counselor will work together to develop a plan for meeting those goals.
You and your counselor will work toward accomplishing your goals by using research-proven methods. These methods include, for example, accessing your inner strengths and resources, changing thoughts that affect how you feel and what you do, or homework assignments in which you try on new behaviors to see how they fit. You and your counselor may decide to involve other family members in your session. Please know that any work in the sessions will occur only with your permission. It is very important to your counselor to see that your limits are respected. Your specific needs and concerns will determine what is done.

Your counselor will frequently take time to examine your progress toward your goals to make sure you both are on the right track. You and your counselor will decide together when your therapeutic goals are met and when to move toward completing therapy.



Client Signature_____________________________Date____________
HIPPA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIION. PLEASE REVIEW IT CAREFULLY.
Effective date: April 14, 2003

The Counseling Office of Life in Balance Counseling and Wellness has been and will always be totally committed to maintaining clients confidentiality. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession.

This notice describes our policies related to the use and disclosure of your healthcare information.
Uses and disclosures of your health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes.
TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services. Which could include consultants and potential referral sources.
PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information maybe used for certification, compliance and licensing activities.
Other uses or disclosures of your information which does not require your consent There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your family members report about physical or sexual abuse, neglect, or exploitation of a child, elderly or disabled person. By Virginia State Law, we are obligated to report this to the Department of Children or Adult Protective Services. If you provide information that informs us that you are in danger of harming yourself or others. Information to remind you of /or to reschedule appointments or treatment alternatives. Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order.
I have read understand the above information:

Client Signature Date



CLIENT RIGHTS & RESPONSIBILITIES

Right to request how we contact you


It is our normal practice to communicate with you at your home address and daytime phone number that you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc.. You have the right to request that our office communicate with you in a different way. Please DONOT provide phone numbers that you do not wish for us to leave messages at. If a phone number is provided as a form of contact the front office will leave a message at that number.

Please check all that apply:

You may contact me:

At home at_____________________Parent’s Name____________________

At work at _____________________  On my cell at____________________

 Please contact me only at the following number _________________________________

Please do not leave a message

Please DONOT Remind me of Appointments

 By e-mail_______________________________________

Right to release your medical records


You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization

Right to inspect and copy your medical and billing records.

You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the office manager. Under limited circumstance we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.


Right to add information or amend your clinical records.

If you feel that information contained in your clinical record is incorrect or incomplete, you may ask us to add information to amend the record. We will make a decision on your request with 60 days, or in some cases within 90 days. Under certain circumstances, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact your therapist. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.



Right to an accounting of disclosures.

You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of the cost involved in preparing this list.


Right to request restrictions on uses and disclosures of your health information.


You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to the therapist. However, we are not required to agree to such a request.

Right to complain.


If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.
Right to receive changes in policy.

You have the right to receive any future policy changes secondary to changes in state and federal laws. This can be obtained from the office manager.


You also have the right:

  • To be treated in a humane and dignified way.

  • To be informed of your treatment options, risks, and benefits.

  • To take an active role in treatment planning.

  • To have questions answered fully.

  • To have confidentiality and privacy within legal/ethical guidelines.

  • To facilitated review of your clinical information.


You have the responsibility:

  • To be honest in providing information.

  • To keep your appointments, to be on time, and to give a 24 hour notice if you should need to cancel your appointment.

  • To be free of alcohol/drugs during your therapy session.

  • To respect the therapist and facility.

  • To respect the privacy and rights of others.

  • To know your insurance requirements, deductibles, and co-pays.

  • To pay your co-pay at the end of each appointment.

__________________________________________________ ______________________

Client Signature Date

Life in Balance Counseling and Wellness Center strives to maintain a peaceful therapeutic environment to enhance well-being and healing. This includes keeping noise and activity levels to a minimum to avoid disrupting services. Many of our services such as meditation, massage, yoga, and hypnosis are best provided in a quiet environment.

All guests at Life in Balance are requested to be considerate of other guests and practitioners by keeping voices at a low level and providing adequate supervision of children.

We would prefer that children always be supervised by a responsible parent or other adult at all times while at Life in Balance. However, we do understand that sometimes it may be necessary to leave them in the waiting and/or play room. Please keep the following in mind:



  1. Life in Balance will neither provide supervision nor assume liability for your children’s safety while they are unsupervised.

  2. Children under the age of 5 should never be left unsupervised.

  3. You must let front desk staff know you are leaving your children in the waiting and/or play room. Staff will need to know children’s names and ages as well as which practioner you are seeing.

  4. Please inform your children left waiting that they must play or sit quietly.

  5. Rough play or disruption to other Life in Balance services, guests, or practitioners will not be tolerated.

  6. Three step process for unruly children:

    1. If your children become disruptive, they will be asked once to curb disruptive behaviors by Life in Balance staff.

    2. If your children continue to be disruptive, staff will request you speak to your children to curb their disruptive behaviors.

    3. If your children continue being disruptive, they will not be permitted to be left unsupervised at Life in Balance again. You will need to make other arrangements for your children while receiving services.

____________________________________ ______________________


Client Signature Date



CLIENT NAME: Date:


PRESENTING PROBLEM AND PAST TREATMENT

Please briefly describe why you are seeking counseling:

________________________________________________________________________________________________________________________________________________________________

How long have you been experiencing this problem?

Have you received counseling before? ______ If so when? ______ Therapist’s Name:

What was the reason for seeking counseling at that time?



What was most helpful about your last counseling experience?

________________________________________________________________________________

What was least helpful about your last counseling experience?

________________________________________________________________________________

Are you receiving other psychiatric services such as: Mental Health Supports Case Management

If yes, Provider’s name Phone # Agency

Have you ever been hospitalized for psychiatric reasons? If so when? ___________

Where? Briefly describe the reason:

Have you ever had Suicidal thoughts? Yes/No

Have you ever attempted Suicide? Yes/No If so when?________________________________

What was going on that lead to these feelings/thoughts? ________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________



SYMPTOMS

Please check any problems that either you have had in the past or are currently having.






Now Past
 Change in appetite (more or less)

 Feeling sad

 Crying spells

 Too little sleep (falling or staying asleep)

Sleep more than usual

 Fatigue

 Loss of interest &/or pleasure

 Avoiding friends or family

 Expect Failure

 Decreased concentration

 Thoughts of death

 Cutting or burning oneself

 Suicide plan or attempt

 Depression

 Often sick

 Loneliness

 Slow Moving

Hopelessness

 Confusion

 Worthlessness

 Friendly

 Lack of confidence/Low self-esteem

 Guilt

 Reckless or dangerous behavior

 Racing thoughts

 Pressured speech

 Inflated self-esteem

 Obsessive thoughts

 Compulsive or repetitive behavior

 Marital/family problems

Sexual problems

 Relationship problems

 Long term memory problems

 Short term memory problems

 Wound up or tense more days than not

 Panic attacks

 Irritable

 Anxiety

 Easy Going

 Muscle tension

 Irrational fear of something or someone

 Talking/acting w/out thinking

 Fidgety, restless, overactive

Difficulty paying attention

 Frequent day dreams

Now Past
 Bored easily

 Learning Difficulties

 Often lose things

 Careless/Reckless behavior

 Excessive dieting/exercise

 Obsessed with losing weight

 Use of laxatives

 Engage in self-induced vomiting

 Eating things that are not food

 Vandalism

 Fire-setting

 Lack of Remorse for wrong-doing

 Selfish

 Bullies/gets in fights

 Lying

 Truancy

 Theft

 Argumentative/sudden anger

 Defiant of authority

 Temper tantrums

 Stubborn

 Avoid Adults

 Afraid to leave a loved one

 Easily Embarrassed

 Upset by minor changes

 Feeling detached from one’s body

 Feelings of unreality

 See or hear things others don’t

 Believe things others tell you aren’t true

 Fear of Strangers

Difficulty trusting

 Believe others are out to get you

 Intrusive thoughts

 Avoid things related to traumatic event

 Startle easily

 Flashbacks

 Nightmares


Other symptoms not mentioned above









SUBSTANCE USE HISTORY
SUBSTANCE History of Use? Date of first Use: Date of Last Use:

Yes No


Alcohol   ______________ _______________

Marijuana   ______________ _______________

Barbiturates   ______________ _______________

Klonopin, Ativan, Xanax,

Valium   ______________ _______________

Cocaine/Crack   ______________ _______________

Heroin/Opiates   ______________ _______________

PCP, LSD, Mescaline   ______________ _______________

Inhalants   ______________ _______________

Amphetamines, Speed,

Uppers, Crystal Meth   ______________ _______________

Designer Drugs, Ecstasy   ______________ _______________

Over the Counter drugs   ______________ _______________

Caffeine   ______________ _______________

Nicotine   ______________ _______________

Other   ______________ _______________

If you are currently using any substances, please describe when and where you typically use: ________________________________________________________________________________________________________________________________________________________________

Please describe how your use affects family and friends, including how they perceive your use: ________________________________________________________________________________________________________________________________________________________________

How do you perceive your use? _____________________________________________

____________________________________________________________________

Have you ever received substance abuse treatment? ____ If yes, when/where? ____________________

Have you ever had the following due to substance use?

Blackouts DUI Seizures Tremors Legal Charges Hallucinations

CASE ASSESSMENT

If you currently or ever have used alcohol and/or recreational drugs or overused prescription drugs, please answer below:

Have you ever felt you ought to cut down on your drinking or drug use? Yes No

Have people annoyed you by criticizing your drinking or drug use? Yes No

Have you ever felt bad or guilty about your drinking or drug use? Yes No

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

Yes No
MEDICAL HISTORY


Physician’s Name

Specialty

What are they treating you for?




Primary Care Physician

























































Date of last physical exam:___________________ Date of last dental exam:

Please list all prescription, non-prescription medications, and supplements below:



Name of Medication

Prescribed by

Dosage/Frequency

Helpful?

Side effects/comments










 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N













 Y  N



Do you take all your medications regularly, as prescribed?

Please mark X if you now have or ever have had any of these conditions:


Hypertension PMS/painful menstruation Seizures

Heart Disease Easy bruising Head injury

Arteriosclerosis Skin Rash  Headaches

High Blood Pressure Allergies Back Pain

Arthritis Skin Sensitivity  Chronic pain

Kidney Disease Environmental sensitivity Fibromyalgia

Varicose Veins Numbness/Stabbing Pain Chronic fatigue

Phlebitis Sensitive to touch/pressure Digestive disorder

Blood Disorder Abscess or Open Sore  Other

Cancer/Malignancy  Infectious Diseases

Diabetes
How does your medical conditions affect your life?
Were you exposed to drugs or alcohol while your mother was pregnant?

Did you have any mental or physical problems growing up (birth defect, learning problems, etc.)?




What types of foods do you usually eat?

What is your activity level? Chores only OR 30 min moderate exercise: 1-2x/wk 3-4x/wk 5-7x/wk

What is your highest adult weight? Lowest adult weight? Current weight?

How many hours do you sleep at night? Do you have trouble: falling asleep? ___ staying asleep? ___


FAMILY HISTORY

Father’s Name: ________________ Living Deceased Age at death: ___ Cause of death:___________

Mother’s Name: _______________ Living  Deceased Age at death: ___ Cause of death:

List yourself and siblings in birth order and include ages:

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

List your children in birth order (living and deceased) and include ages:

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

List all current members of your household (people who live with you):

____________________ _________________________ _________________________

____________________ _________________________ _________________________

____________________ _________________________ _________________________

Do you have any pets? If so what type and their name:

____________________ _________________________ _________________________

____________________ _________________________ _________________________

If involved in an intimate relationship (spouse, partner, fiancé, boyfriend/girlfriend, etc.), please describe your relationship: _________________________________________________________________________________________


Have you ever been emotionally/mentally, sexually or physically abused? ________________________________________________________________________________
________________________________________________________________________________
WORK, SOCIAL AND LEISURE ACTIVITIES
Are you currently working? _____ If so, where? ___________________________________________
Does your job involve hazardous duties, irregular shifts or other potential stressors? ________________

Do you like your job? ______ If no, what would you rather do?

Did you serve in the military? Branch How long? Combat exposure?


How far did you go in school? __ grade K-8 __ grade 9-12 __ Graduated H.S. __ Some undergrad college __ Bachelor’s degree __ In grad school __ Master’s or doctorate degree
Who do you turn to for support?
What do you do for fun? _____________________________________________________________
________________________________________________________________________________
What do you do for relaxation? ________________________________________________________
________________________________________________________________________________

SPIRITUAL

Would you say you are spiritual or religious in any way? Please explain activities: ____________________


Do you have any regular spiritual practices or rituals?

Have you had any loss or death in your life that is currently causing you distress? If so, please describe:

How do you cope with loss and/or death?



CULTURAL

What language(s) are spoken in your household?

How would you describe yourself ethnically or culturally?

Do you have any physical disabilities? Do you have limitations on vision, hearing, or speech?



FINANCIAL HISTORY

What are your sources of income?

Do you receive any kind of assistance with food, housing, or other necessities? ­

Do you struggle with your bills? Do you have your own transportation?



LEGAL HISTORY

□ No legal history

 Current legal charges (describe) ______________________________________________________

 History of involvement in legal system (describe) __________________________________________

________________________________________________________________________________

 Involvement with Social Services (describe) _____________________________________________



Is there anything else not written above that would be helpful for me to know?





Thank you for the time and effort you invested in completing this paperwork. This will help me to understand you more fully and be better able to assist you on our journey together.

Reviewed above with client:

__________________________________________________ _______________

Therapist Signature Date

__________________________________________________ _______________

Supervisor Signature (if applicable) Date




Authorization to Release Protected Health Information (PHI)
I (Client’s Name) __________________________________ (Date of Birth)_______________ give permission to Life In Balance Counseling and Wellness Center and
__________________________(Clinician’s Name) to send and/or discuss confidential case records and/or test results, to send treatment summaries and diagnosis information to and to receive confidential information from my PRIMARY CARE PHYSICIAN/PSYCHIATRIST/OR DESIRED PERSON OR ENTITY:

Name:_________________________________________________________

Address:_______________________________________________________

______________________________________________________________

Phone:______________________________Fax_________________________

I understand my service record is protected under Federal and State regulations and that information to be released by my signature may contain information pertaining to medical, psychiatric, substance abuse treatment and/or confidential HIV/AIDS related information.

This consent shall be in effect from____________________until________________________

(Not longer than one year)


____________________________________ ________________

(Signature of Patient) (Date)
_________________________________________________ _________________________

(Signature of Witness) (Date)




Initial __________



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