NEW CLIENT INTAKE FORM

Name

First Name

Last Name

Address

Apartment, suite, etc. (optional)

City

State

Zip Code

Date of Birth

Format: MM/DD/YYYY

Parent/Guardian Name

*If client is a minor

Occupation

Phone Number

Format: 123-456-789

Email Address

Presenting Concern

What's the reason you are seeking therapy?

Current Medications

Have you ever been in therapy before? If yes, please elaborate.

Do you have a history of mental health issues in your family? If yes, please elaborate.

Do you have any medical issues? If yes, please elaborate.

Are you currently or have you ever experienced suicidal ideation? If yes, please elaborate.

Do you struggle socially? If yes, please elaborate.

Do you have any issues at school? If yes, please elaborate. If not applicable, please write N/A.

Do you have any problems at home and/or family issues? If yes, please elaborate.

What do you hope to work on while in therapy? (i.e. goals for treatment)

Is there anything else you want your therapist to know about you?

HEALTH INSURANCE

Positive Perspective Therapy, LLC is out of network with all health insurance companies. This means that you are responsible for the full fee/agreed upon fee at the time of the session. If your health insurance plan has out of network benefits for mental health and you would like to have Positive Perspective therapy submit claims to your health insurance on your behalf, this can be arranged. By checking the box below, you are consenting to have Positive Perspective Therapy submit out of network claims to your insurance company on your behalf and that your health insurance company will send reimbursement to Positive Perspective Therapy directly.

I consent to the above terms.

CONSENT FOR TREATMENT OF ADULT/MINOR

By signing this form, you are providing legal consent to and financial responsibility for counseling services for yourself or for your minor child. These statements are important to protect the child, the parent/guardian, and the practice. Positive Perspective Therapy, LLC will provide therapy and counseling services, which can include but are not limited to: individual sessions, family sessions, parent sessions, coordination of care with other professional providers and/or treatment team planning sessions. Positive Perspective Therapy, LLC also has the ability to collaborate with school personnel and/or other professionals (psychiatrists, doctors) involved to coordinate care and services. A separate HIPAA form must be signed for this communication to occur. Please consult with your therapist if you would like them to contact other professionals involved and they will provide you with that form. For minor clients: The parent/guardian is legally responsible for the minor being treated and grant permission to Positive Perspective Therapy, LLC to conduct therapy with this minor.

I consent to the above terms.

PAYMENT & FEES

The adult client/parent/guardian accepts responsibility for the timely payment of all fees due to Positive Perspective Therapy, LLC for services provided. Please carefully review the agreed upon fee and payment information. By signing this form, you are providing Positive Perspective Therapy, LLC with permission to charge your credit card (through the Square app) the agreed upon fee or for Positive Perspective Therapy, LLC to accept electronic payments (Venmo, Zelle, Paypal) from the client. You are encouraged to discuss any questions regarding payment or fees you may have with Alexa Squire, LMFT, ACS (Owner of Positive Perspective Therapy.) It is our policy to have a credit card on file so that when your session occurs each week, your credit card will be charged ensuring a seamless payment process.

I consent to the above terms.

CC Number

Expiration

CVC

Billing Zip Code

Email Address

For receipts

DUTY TO WARN NOTICE

Positive Perspective Therapy, LLC is committed to the confidentiality and privileged communication with all clients. There are, however, several exceptions. According to New Jersey law, any evidence of child/elder abuse or neglect must be reported to the authorities. If any individual intends to take harmful, dangerous, or criminal action against another individual, or against himself/herself, it is the therapist’s duty/obligation to report such action or intent and break confidentiality. It is also important to note that some therapists on the Positive Perspective Therapy team are provisionally licensed. This means that they are working towards their clinical hours in order to obtain full licensure. They are under direct supervision of a clinical supervisor who will assist them with clinical decisions when necessary.

I consent to the above terms.

PROVISIONALLY LICENSED THERAPISTS

The following therapists have a provisional license: *Katelyn Farrell, LSW, LCADC (Supervisor: Stephanie Domnitz, LCSW 973-715-9921) *Amanda Pollifrone, NCSP, LAMFT (Supervisor: Alexa Squire, LMFT, ACS) *Brooke Elliott, MA, LAC (Supervisor: Alexa Squire, LMFT, ACS) *Sophia Mercer, AMFT (Supervisor: Alexa Squire, LMFT, ACS *Samantha Voltmer, LSW (Supervisor: Dr. Sharon Bale-Peña, DSW, LCSW, PMH-C, Verdant Counseling, Sbalepena@verdantcounselingnj.com 201- 477-8011) Please note that the following master's level intern has not yet obtained a clinical license to practice but is under direct clinical supervision. *Rebecca Pine (Gabriella Fink, MA, LPC, NCC 201-230-9017) If you need additional information or have questions about this, please discuss them with your therapist or with Alexa Squire.

I consent to the above terms.

CONFIDENTIALITY

Positive Perspective Therapy, LLC will protect your personal and health information. In the event of an emergency or crisis situation, your therapist can use their clinical judgment to release information in efforts of keeping clients safe.

I consent to the above terms.

ELECTRONIC COMMUNICATION

I understand that email, phone calls, voicemail and text messaging may not be a secure/confidential means of communication. Positive Perspective Therapy, LLC will utilize these forms of communication for managing appointments, requesting direct communication or for telehealth sessions (video chat or telephone call sessions.)

I consent to the above terms.

CANCELLATION POLICY

Positive Perspective Therapy, LLC requests that in the event a client needs to cancel their appointment, they do so within a 24-hour time period prior to the date/time of the appointment. Clients will be charged a $100 fee per session that is not cancelled within the 24 hour time frame.

I consent to the above terms.

If Minor client, please print Full Name:

If not applicable, please input N/A

If Parent/Guardian/Adult client, please print Full Name:

If not applicable, please input N/A

Electronic Signature

Your signature below shows that you agree to the above terms and conditions.

Date

YYYY

*If you would like your therapist to coordinate care with an outside person or company, please take a moment and fill out our Release of Information form, which can be found here.