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Intake Paperwork Couples Roy Spaulding MS LMFT

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					Spaulding Counseling Services

                              Client Information Form
The following information will help me serve you better and will be kept confidential with the
limits described on the disclosure statement. If you have any questions, feel free to ask.

Today’s Date: _________________

Name: ______________________________ Age: _____ Birth Date: ________ Gender: ______

Street Address: ________________________________                Social Security #:___________

City: ________________             State: _____________                Zip Code: ___________

Phone Numbers: Home: ____________ Work: _______________ Cell: _________________

Place of Employment:__________________________________
Job Duties:____________________________________________________________________

Emergency Contact Person: _______________________ Phone Number: ________________
------------------------------------------------------------------
Medical Information

Physician: ______________________________________

When did you last see your physician? _____________________________________________

Please list any medications you are currently taking, including psychotropic medications:
______________________________________________________________________________

Please describe any medical conditions I should be aware of:
______________________________________________________________________________
-------------------------------------------------------------------
Family Information
Relationship Status (please check any that apply):
Married _____ Separated _____ Divorced _____ Single _____ Living together _____
Committed partnership _____ Widowed _____ Other (specify) _____

Religious Affiliation: _________________________

Name of Spouse/Partner: ______________________ Age: _____ Gender: _____

Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____



                                                                Case #_______________
Current Information

What problems are you experiencing at this time?
______________________________________________________________________________
______________________________________________________________________________

What would you like to see different as a result of therapy?
______________________________________________________________________________
______________________________________________________________________________

Have you had any previous therapy or counseling experience? (circle one) Yes  No
If yes, please describe what it was for: ______________________________________________

Please describe your current alcohol and/or drug use (what type and how often):
______________________________________________________________________________

Please describe any past or current experiences with domestic violence:
______________________________________________________________________________
______________________________________________________________________________

Please describe any current or past suicidal thoughts or attempts:
______________________________________________________________________________
______________________________________________________________________________

Please describe any experiences that you would consider traumatic or highly troubling:
______________________________________________________________________________

What do you consider as your strengths at this time?
______________________________________________________________________________
______________________________________________________________________________

Please describe any other information I should know about you or your situation:
______________________________________________________________________________
______________________________________________________________________________
-------------------------------------------------------------------

How did you hear about my services? _______________________________________________




                                                         Case #_______________
Spaulding Counseling Services

                              Client Information Form
The following information will help me serve you better and will be kept confidential with the
limits described on the disclosure statement. If you have any questions, feel free to ask.

Today’s Date: _________________

Name: ______________________________ Age: _____ Birth Date: ________ Gender: ______

Street Address: ________________________________                Social Security #:___________

City: ________________             State: _____________                Zip Code: ___________

Phone Numbers: Home: ____________ Work: _______________ Cell: _________________

Place of Employment:__________________________________
Job Duties:____________________________________________________________________

Emergency Contact Person: _______________________ Phone Number: ________________
------------------------------------------------------------------
Medical Information

Physician: ______________________________________

When did you last see your physician? _____________________________________________

Please list any medications you are currently taking, including psychotropic medications:
______________________________________________________________________________

Please describe any medical conditions I should be aware of:
______________________________________________________________________________
-------------------------------------------------------------------
Family Information
Relationship Status (please check any that apply):
Married _____ Separated _____ Divorced _____ Single _____ Living together _____
Committed partnership _____ Widowed _____ Other (specify) _____

Religious Affiliation: _________________________

Name of Spouse/Partner: ______________________ Age: _____ Gender: _____

Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____
Name of Child:   _____________________________ Age: _____ Gender:          _____


                                                                Case #_______________
Current Information

What problems are you experiencing at this time?
______________________________________________________________________________
______________________________________________________________________________

What would you like to see different as a result of therapy?
______________________________________________________________________________
______________________________________________________________________________

Have you had any previous therapy or counseling experience? (circle one) Yes  No
If yes, please describe what it was for: ______________________________________________

Please describe your current alcohol and/or drug use (what type and how often):
______________________________________________________________________________

Please describe any past or current experiences with domestic violence:
______________________________________________________________________________
______________________________________________________________________________

Please describe any current or past suicidal thoughts or attempts:
______________________________________________________________________________
______________________________________________________________________________

Please describe any experiences that you would consider traumatic or highly troubling:
______________________________________________________________________________

What do you consider as your strengths at this time?
______________________________________________________________________________
______________________________________________________________________________

Please describe any other information I should know about you or your situation:
______________________________________________________________________________
______________________________________________________________________________
-------------------------------------------------------------------

How did you hear about my services? _______________________________________________




                                                         Case #_______________
Spaulding Counseling Services
1552 N. Crestmont Dr., Suite. C
Meridian, ID 83642
887-1911


                     Disclosure Statement and Treatment Consent
The following information describes the therapeutic services I provide as a Licensed Marriage and Family Therapist
and your rights as a consumer of these services. Please feel free to request any further clarification of the
information provided.

I hold a Master’s degree from Colorado State University in Marriage and Family Therapy and am licensed to
practice in the state of Idaho. My clinical experience is diverse and includes four years experience with high-risk
youth, one year in child protection and foster care, three years with adult drug and alcohol abuse, and five years of
Marriage and Family Therapy. I also have specialized training in child-centered and filial play therapy. I am
regulated as a therapist by the State of Idaho Bureau of Occupational Licenses (IBOL).

As a therapy consumer, you have the following rights:

          You have the right to receive information concerning the methods of therapy employed, the techniques
           used, the duration of therapy (if known), and the fee for services provided
          You have the right to seek a second opinion from another therapist
          You have the right to terminate therapy at any time (however, should you decide to terminate therapy, I
           request that you discuss your decision with me to ensure adequate closure)
          You should be aware that sexual intimacy is never appropriate in a professional relationship and should be
           reported to the Grievance Board
          You have the right to know that all information disclosed during therapy is legally confidential and will not
           be revealed to any other person or agency without your written permission.
          You should know that there are certain exceptions to the confidentiality laws. I am required by law to
           reveal information obtained during therapy to other persons or agencies without your permission. I am not
           required to inform you of my actions in this regard. These situations are as follows:
                 if I believe you are in imminent danger to yourself or others
                 if I suspect any child abuse or neglect of any children
                 if I am ordered to release information by a court of law
          You have the right to have your medical insurance billed for the services received by Roy Spaulding, MS,
           LMFT and to know that the information gathered during your therapy sessions (including diagnosis)
           becomes a permanent part of your medical records and may affect future insurability and coverage.

As a Marriage and Family Therapist, I am qualified and trained to help individuals, couples, families, and children.
I take a systemic approach to problems using strength-based models such as Emotionally Focused and Narrative
therapies. These approaches will help you find efficient and lasting resolution to the problems for which you are
seeking therapy.

In order to provide the highest quality treatment possible, information provided during therapy will be available to
Cameron Preece, LMFT, Ph.D. and William Hansen, with whom I collaborate. As part of this supervision and
collaboration, I request permission to video or audio record our sessions. These recordings will be reviewed for
supervision purposes only and will be erased once a month. Office staff will also have access to limited information
and are likewise bound by strict confidentiality laws. By signing below, you are acknowledging that you have read
and received a copy of this statement and are consenting to treatment. If billing insurance, you are also giving
consent for Roy Spaulding, MS, LMFT to release any requested information to your insurance company and to
receive direct payment from your insurance company.
[ ]        Consent to video or audio tape sessions for supervision purposes only.
Initials

Client Signature      ___________________________________________                          Date ________________

Therapist Signature ___________________________________________                            Date ________________



                                                                                Case #_______________
Spaulding Counseling Services

                                            Financial Agreement Form
I have discussed and agree to the following financial payment and procedures.

      1. To pay $150 for the initial assessment and $100 per 50 minute session thereafter.

      Explanation of any alternate payment plan:
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      2. Payment is expected at the beginning or end of each session, unless I have made prior
         arrangements.
      3. You will be charged a prorated fee for consultations over the phone that involves
         therapeutic issues other than obtaining and canceling appointments.
      4. Appointments not cancelled 24 hours in advance may be charged to my account and must
         be paid at the next session.
      5. A $20 service charge will be added to all returned checks and must be paid at the next
         session.

           I would like Spaulding Counseling to bill my insurance.
Initials   (Payments of fees are the full responsibility of the client. Insurance is billed as a courtesy only and does not guarantee that all fees
           will be covered by insurance)


Insurance Information
Name of Insurance Company: ____________________________________________________
Insurance Company Address: _____________________________________________________
(City)_______________________________ (State)___________ (Zip Code)_______________
Phone Number: _______________________
Subscriber Name: ________________________________ Date of Birth: __________________
Place of Employment: ___________________________________________________________
Policy ID or Social Security Number: _______________________________________________
Group Number: _________________

I understand the above payment procedures and I agree to this plan of payment.

Client Signature           _____________________________________                                      Date ________________


Therapist Signature _____________________________________                                             Date ________________




                                                                                                 Case #_______________
Spaulding Counseling Services

                   Couples and Family Release of Information

Part of my philosophy of therapy is that in working with couples and families, honesty between
individuals is important and keeping secrets is typically damaging to relationships. In order to
help your family solve their problems, having the option to discuss information from sessions is
vital. I will use my clinical judgment in regards to sharing information in couple and family
sessions, and will not disclose in situations where your safety may be at risk.

I, ____________________________, understand that because I am seeking couple or family
          (name of client)
therapy, information that I share with Roy Spaulding individually may not be kept confidential
from my partner or family members who are also seeking therapy. I authorize Roy Spaulding,
M.S., LMFT to communicate any information provided by me to
_____________________________________________________________________________.
                      (name of partner and/or family members)
I understand that in cases where sharing of such information could put my safety or the safety of
others at risk, information may not be disclosed.



I understand that my records are protected under Federal and State Confidentiality laws and
cannot be disclosed without my written consent, unless otherwise provided for in the regulations.
I also understand that I may revoke this consent at any time by submitting a written request to
my therapist, Roy Spaulding, M.S., LMFT. Unless otherwise requested, my consent will expire
automatically one year from the date signed.

The date, event, or condition upon which this consent expires is one year from date signed unless
otherwise noted below:

______________________________________________________________________________

______________________________________________________________________________


Client Signature   ___________________________________________            Date ________________


Therapist Signature ___________________________________________           Date ________________




                                                                Case #_______________
Spaulding Counseling Services

                   Couples and Family Release of Information

Part of my philosophy of therapy is that in working with couples and families, honesty between
individuals is important and keeping secrets is typically damaging to relationships. In order to
help your family solve their problems, having the option to discuss information from sessions is
vital. I will use my clinical judgment in regards to sharing information in couple and family
sessions, and will not disclose in situations where your safety may be at risk.

I, ____________________________, understand that because I am seeking couple or family
          (name of client)
therapy, information that I share with Roy Spaulding individually may not be kept confidential
from my partner or family members who are also seeking therapy. I authorize Roy Spaulding,
M.S., LMFT to communicate any information provided by me to
_____________________________________________________________________________.
                      (name of partner and/or family members)
I understand that in cases where sharing of such information could put my safety or the safety of
others at risk, information may not be disclosed.



I understand that my records are protected under Federal and State Confidentiality laws and
cannot be disclosed without my written consent, unless otherwise provided for in the regulations.
I also understand that I may revoke this consent at any time by submitting a written request to
my therapist, Roy Spaulding, M.S., LMFT. Unless otherwise requested, my consent will expire
automatically one year from the date signed.

The date, event, or condition upon which this consent expires is one year from date signed unless
otherwise noted below:

______________________________________________________________________________

______________________________________________________________________________


Client Signature   ___________________________________________            Date ________________


Therapist Signature ___________________________________________           Date ________________




                                                                Case #_______________