Client Intake Form — Rosen Akeson Therapy

Age

Email

Emergency Contact Name

Emergency Contact Number

Preferred Pronouns

Spirituality

FAMILY INFORMATION

Spouse/Partner Name

Spouse/Partner Age

List Child/Children Name(s) / Age(s) / Do they live with you?

FAMILY HISTORY

Who were you raised by?

Please describe your relationship with your parents/caregivers:

Please describe names, ages, and respective relationships with your siblings:

If there are any circumstances from your childhood that you'd like to elaborate on, please do so here:

SUPPORT SYSTEM

Please explain:

What is your current living situation?

If no, pease explain why:

EMPLOYMENT/EDUCATION STATUS

Employer/School:

Occupation/Years in School:

MENTAL HEALTH HISTORY

If yes, please explain:

Previous therapist

Dates seen

MEDICAL HISTORY

If yes, please list:

If yes, please list all symptoms and treatments you are undergoing:

Physician

Physician Phone Number

STRESSORS

If other, please explain:

Please List Top 3 Stressors

PERSONAL HISTORY

If other, please explain:

How long have you been dealing with these symptoms?

HABITS & LIFESTYLE

If yes, how often:

If yes, please explain:

If yes, please describe what you do and how often:

If yes, what are they and how often do you do them?

What do you do for fun?

LEGAL SUMMARY

If yes, please explain:

GOAL INFORMATION

Please answer the following questions to the best of your ability:

Why are you seeking treatment at this time?

What would you like to change about yourself or your circumstances?

What gives you hope, purpose, and meaning?

What do you hope to get from treatment?

CANCELLATION & NO SHOW POLICY

Your appointment is very important. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully request at least 24 hours' notice prior to your scheduled appointment time for cancellations or rescheduling of appointments. Please notify us by e-mail if your cancellation is outside of our normal business hours or you’re unable to reach us by phone at (203) 293-0258. ALL NO-SHOWS AND ANY APPOINTMENTS CANCELLED, RESCHEDULED, OR CHANGED WITHOUT 24 HOURS' NOTICE WILL BE BILLED TO YOUR ACCOUNT IN THE AMOUNT WE WOULD HAVE COLLECTED IF THE SERVICE HAD BEEN PROVIDED AS SCHEDULED. It is mutually understood that if a cancellation is due to circumstances beyond any of our control, such as power outage, unfortunate incidence, illness, or weather that requires you or us to have to cancel or be closed during regular business hours, we will reschedule your existing appointment and no discount or rescheduling fee will apply. ARRIVAL TIME Please arrive on time to your scheduled appointment time. All therapy has a specific time schedule. A prompt arrival allows for a relaxed experience. If you arrive late, your therapy may be shortened in order to maintain our schedule. LATE ARRIVAL POLICY All appointments begin and end on time in order to maintain our schedule. If the therapy does not start on time due to client tardiness, the therapy time will be reduced accordingly and you will still be required to pay full price. If a client is more than 20 minutes late, the appointment may be considered a cancellation.

INFORMED CONSENT FOR COUNSELING & PSYCHOTHERAPY

This informed consent document is intended to provide general information about the counseling services provided by Rosen Akeson Therapy. This is a legal document; please read it carefully before signing. MENTAL HEALTH SERVICES Rosen Akeson Therapy recognizes that it may not be easy to seek help from a mental health professional. It is your therapist’s intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to your therapist and the specifics of your situation, your therapist will provide recommendations to you regarding your treatment. We believe that therapists and patients are partners in the therapeutic process. You have the right to agree or disagree with your therapist’s recommendations. Due to the varying nature and severity of problems and the individuality of each patient, your therapist is unable to predict the length of your therapy or to guarantee a specific outcome or result NATURE OF THERAPY & RISKS It is important to understand that there are both benefits and risks associated with participation in therapy. Therapy may improve the ability to relate to others, provide a clearer understanding of self, values, and goals, and an ability to deal with everyday stress. However, clients often learn things about themselves that they don’t like. Often growth cannot occur until past issues are experienced and confronted, often causing distressing feelings such as sadness and anxiety. Therapy can lead to unanticipated feelings and change, which might have an unexpected impact on you, and your relationships. RELATIONSHIPS The relationship you have with your therapist is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that your therapist not have any other type of relationship with you. It is not appropriate to share gifts, barter, or trade services with your therapist. CONFIDENTIALITY Discussions between you and your therapist are confidential. No information will be released without your written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; criminal prosecutions; child custody cases, suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn, notify, or disclose. If you have any questions regarding confidentiality, you should bring them to the attention of your therapist when you and the therapist discuss this matter further. AFTER-HOUR CONCERNS & EMERGENCIES As a general rule, it is our belief that important issues are better addressed within regularly scheduled sessions. However, you may contact your therapist in between sessions. You may leave a message for your therapist at any time on his/her confidential voicemail. If you wish your therapist to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. In the event of a medical or psychiatric emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance. COMMUNICATION By signing the Informed Consent for Counseling and Psychotherapy document, you are consenting for Rosen Akeson Therapy to communicate with you by phone, e-mail, and at the address provided on your client intake form. You agree to notify us if you need to opt out of any form of communication. FEES The fee for individual therapy sessions are $190 per session and are approximately 50 minutes in length. The fee for conjoint (marital /family) therapy sessions are $220 per session and approximately 50 minutes in length. Fees are payable at the time that services are rendered, unless otherwise mutually agreed upon. If for some reason you find that you are unable to continue paying for your therapy, you should inform your therapist as soon as possible. Your therapist will help you to consider any options that may be available to you at that time. INSURANCE & PAYMENT Rosen Akeson Therapy is not accepting insurance at this time, However, many insurance companies will reimburse you for a portion of the cost of your session. We are happy to assist you in that process. Rosen Akeson Therapy accepts payment via check, Zelle and Venmo. Payments made through Vemno will be charged an additional four dollars to cover processing fees. Please discuss any questions or concerns that you may have with our billing and scheduling coordinator. NOTICE TO CLIENTS The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830. CONSENT TO TREAT By signing the Informed Consent for Counseling and Psychotherapy, you voluntarily agree to receive mental health assessment, care, treatment, or services and authorize the therapist to provide such care, treatment, or services as are considered necessary and advisable. Signing indicates that you understand and agree that you will participate in the planning of your care, treatment, or services and that you may stop such care, treatment, or services at any time. By signing the Informed Consent for Counseling and Psychotherapy document you acknowledge that you have both read and understood all the terms and information contained herein. You also agree that you have had the opportunity to ask questions and seek clarification of anything that remains unclear and that those questions have been answered satisfactorily.

New Client Intake Form