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Client Intake & Consent Form

Let's start with the basics.

What is your first and last name?

How do you identify?

How do you identify?
A
B
C

How would you like me to refer to you?

How would you like me to refer to you?
A
B
C
D

DOB:

Contact Number

What is your email address?

Emergency Contact Number

Let's dive deeper!

What are your concern areas?

What are your concern areas?

Have you taken counseling services previously?

What's your health like?

Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?

What, if any, significant medical condition(s) and/or injuries have you been diagnosed with (currently or in the past)?

What, if any, specific health concerns, such as illnesses, pain, and/or injuries do you have?

What, if any, medications, either over-the-counter or prescriptive, are you taking?

On a scale of 1-10, how would you rank your health right now?

0 being "it totally sucks" and 10 being "I should be my own species I'm so healthy"
On a scale of 1-10, how would you rank your health right now?

Disclaimer

Counseling is a collaborative process between the client and the therapist. The therapist provides a supportive and non-judgmental environment to help clients work through their challenges and achieve their goals. This informed consent document will provide important information about the counseling services, the benefits & risks of counseling, and your rights as a client.

I understand that I will be receiving counseling services from Ms. Priyanka B.

The purpose of counseling is to address my mental, emotional and behavioral concerns & to help me cope and manage my symptoms and over-all well being

Confidentiality 

I understand that all information shared during counseling sessions will be kept confidential, except in the following situations:

✓  If it is determined that I am an immediate danger to myself or others, my mental health provider may have a duty to warn or protect those who may be at risk.
✓ If it is suspected that child abuse, elder abuse, or dependent adult abuse is occurring, my mental health provider is required by law to report this to the appropriate authorities.
✓ If I sign a release of information form, my mental health provider may share information with other healthcare providers, family members, or other individuals at my request.
✓ I understand that my mental health provider may consult with other healthcare professionals or supervisors to provide the best possible care to me.

I agree.

I agree.
A

Limitations of Counseling Services

1. I understand that counseling is not a substitute for medical or psychiatric treatment, and my mental health provider is not a medical doctor or psychiatrist. If my mental health provider believes that I need medical or psychiatric treatment, they may refer me to a medical doctor or psychiatrist.
2. I understand that counseling is not a guarantee of specific results or outcomes and that I am responsible for my own progress and success in counseling.

Risks and Benefits

I understand that counseling may involve discussing unpleasant or difficult topics, and that I may experience uncomfortable emotions during counseling sessions. 
However, I also understand that counseling may help me improve my coping skills, develop stronger relationships, and achieve my goals.

I agree to attend the counseling session after fully understanding the working process and agree to adhere to them accordingly.

I agree to attend the counseling session after fully understanding the working process and agree to adhere to them accordingly.
A