Intake Form

Adamstown Touch of Peace
Julia Jay LSW
Po Box 745
Adamstown, PA 19501

Dear potential client:
Thank you for contacting me at A Touch of Peace. I look forward to talking with you further on your first visit scheduled
Because we want your session time to be spent talking about the things that are important to you, and not “paperwork details”, I am enclosing some information for you to read at your convenience prior to your first visit to ATOP. This may answer some of your questions and save time.

Please complete at least the first 4 of the attached pages and bring this entire document to your first appointment.

If you need further assistance please feel free to contact the office @ 717-484-1253 or contact me personally on my cell if I do not answer within a few hours @ 717-587-2025

Sincerely,

Julia Jay LSW

 

 

CONFIDENTIAL CLIENT INTAKE FORM

Name: ________________________________ Today’s Date: __________________

Address______________________________________ Sex:  Male   Female

Date of Birth: ________________ Age: ________

Home phone: _____________________ Work phone: _______________________

Cell phone: _________________________

Which number do you prefer to have messages received at:?

Check here if you want Christian counseling ? YES  NO

Do you regularly attend a church, synagogue, or other religious institution?         Yes ?                  No
If yes, name of congregation _________________________________________________

• RELATIONAL INFORMATION
Current marital status: ? Single ? Engaged ? Married ? Separated ? Divorced ? Widowed
If engaged, married, separated, divorced, or widowed, for how long?
Number of previous marriages for you. _________

For your spouse. _______
If married, spouse’s name: _________________________ Age: ____________
Is your spouse supportive of you seeking counseling? ? Yes ? No ? Unsure ?      Spouse doesn’t know

Please provide a brief description of your spouse (e.g., angry and controlling; outgoing and supportive):

 

What is your current occupation?

What is your level of satisfaction with your occupation?     Circle completely satisfied acceptable unsatisfied Looking for another job

Please list your children, if any (including step, adopted, foster) below:

 

 

Name, sex, Age, Relationship to you, Living with whom?

Who else lives with you? ___________________________________________________

Please list your father, mother, sisters, brothers, stepfamily relations, or other family members who had a significant effect on your life (either positive or negative). (Use the back of this sheet if necessary.)

Name, Sex, Age,  Describe Relationship him/her
(e.g. angry, outgoing, supportive, controlling)

COUNSELING HISTORY
If you have had any previous counseling, psychiatric treatment, substance abuse treatment, or residential/in-patient care, please list the names of the therapists or programs. (Use the back if necessary.)

Therapist’s Name or Program Major Issue Dates

Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues, or psychiatric conditions?
? Yes ? No
If yes, please describe: _______________________________________________

Have any of your family members or friends ever attempted or committed suicide?
? Yes ? No
If yes, who and when: _______________________________________________
• MEDICAL HISTORY
Please list any conditions, illnesses, treatments, or surgeries that might be relevant to your reason for seeking counseling:

Are you currently receiving any medical treatment? ? Yes ? No
If yes, please describe:

Please list all current medications you are taking and the reasons for taking them. (List even if you seldom use, or take only as needed.)
Name of medications Dose Reason for taking

Are you taking these medications according to the doctor’s recommendations?
Yes No
If no, please explain:
Date and outcome of last physical exam and Dr. Name, Location: ______________________________________

• PRESENT ISSUES AND GOALS
Please describe why you are coming to counseling. (i.e. what are your issues, problems, symptoms, how long, etc. Use the back if necessary.):
Check any of the following symptoms or problems that you currently are or recently have experienced

List 1 List 2 List 3
? Stress ? Marital Problems ? Compulsive Behaviors
? Anxiety ? Other Relational Problems ? Seeing Things Others Don’t
? Panic ? Physical Abuse ? Hearing Voices
? Depression ? Emotional Abuse ? Racing Thoughts
? Apathy ? Verbal Abuse ? Eating Problems
? Fatigue/Lack of Energy ? Sexual Abuse ? Drug Use
? Loss of Appetite/Overeating ? Sexual Problems ? Alcohol Use
? Trouble Sleeping ? Gender Identity Issues ? Pregnancy
? Poor Concentration ? Anger ? Abortion
? Feeling Worthless ? Aggressive Behavior ? Legal Matters
? Recent Death ? Bad Dreams ? Work Stress
? Grief ? Unwanted Memories ? Career Choices
? Chronic Pain ? Loss of Control ? Indecisiveness
? Loneliness ? Impulsive Behavior ? Parenting Problems
? Fears ? Controlling ? Financial Problems
? Shyness ? Controlled by Others ? Spiritual Problems
? Low Self-Esteem ? Obsessive Thoughts ? Other _____________________

Please use an “X” on the scale below to indicate how distressing your problem(s) are to you.

[———————————————————————————–]
Very Distressed         Moderately Distressed                     Minimally Distressed
Are you currently experiencing any suicidal thoughts? ? Yes ? No
Have you experienced suicidal thoughts in the past? ? Yes ? No
Have you attempted suicide in the past? ? Yes ? No
Are you currently experiencing any violent or homicidal thoughts?
? Yes ? No

What do you hope to gain from this counseling experience?

_________________________________________________ _________________
Client’s Signature Date

 

 

 

POLICIES AND PROCEDURES

Welcome to ATOP. Please read all documents thoroughly and complete them, where necessary, so that you are prepared to discuss any questions with me during our first meeting.

1. RELEASE OF INFORMATION FORM

All information obtained/derived by the course of treatment is fully confidential; disclosures you share with me are confidential unless you have SIGNED a consent form to release part or all of the information.

Therefore, to either release or obtain information from a specific individual or agency, a Release of Information must be obtained. Exceptions to this guideline include instances when 1) the patient is a clear danger to (a) themselves or (b) others and, 2) instances when the patient is a minor (under the age of 18) and reports that he or she is or has been a victim of physical or sexual abuse, and 3) there is any suspected abuse to a child or adult. Please sign and date all Release of Information documents.

In addition, cases are occasionally discussed by the clinic’s professional staff to obtain feedback and provide alternative treatment plans and continuity of care Your signature on this form will allow this process to proceed smoothly.

2. TELEPHONE CALLS
If there is an emergency and I am unable to be reached, call 911 or go immediately to your local Emergency room.

3. FEES AND PAYMENT
This will be discussed on first meeting, a financial determination sliding scale fee will be used but no one will be turned away because of inability to pay.

4. CANCELLATIONS AND MISSED APPOINTMENTS
When an appointment is scheduled, that time is reserved for you. If the appointment is missed or canceled without sufficient notice, I am unable to make use of that time. Therefore, sessions must be canceled 24 hours in advance or a cancellation fee of $20 will be charged upon discretion.

I trust that your involvement within this Professional System will be helpful and profitable to you. If you have any questions regarding these arrangements or other aspects of your relationship with me, please discuss them with me as the situation arises.

This is to certify that I have read, understand, and have been given a copy of this document.

Patient’s Signature ___________________________________ Date ___________

POLICIES AND PROCEDURES
Please read all documents thoroughly and complete them where necessary, so that you are prepared to discuss any questions at the time of our meeting.
1. RELEASE OF INFORMATION FORM
All information obtained/derived by the course of treatment is fully confidential; disclosures you share with your social worker are confidential unless you have SIGNED a consent form to release part or all of the information.
Therefore, to either release or obtain information from a specific individual or agency, a Release of Information must be obtained. Exceptions to this guideline include instances when 1) the patient is a clear danger to (a) themselves or (b) others and, 2) instances when the patient is a minor (under the age of 18) and reports that he or she is or has been a victim of physical or sexual abuse, and 3) there is any suspected abuse to a child or adult. Please sign and date all Release of Information documents.
In addition, cases are occasionally discussed by the clinic’s professional staff to obtain feedback and provide alternative treatment plans and continuity of care Your signature on this form will allow this process to proceed smoothly.

2. TELEPHONE CALLS
Occasionally the need to talk to your therapist may arise between normally scheduled sessions. It is difficult to conduct evaluations over the phone but your social worker will respond to your call during normal business hours. A charge will be incurred by the patient for any telephone consultation time between schedules sessions with social worker. If there is an emergency and professional at ATOP is unable to be reached, call 911 or go immediately to your local Emergency room.

3. LENGTH OF SESSION
The professional session is about 45-50 minutes in length beginning at our appointed time and concluding 45-50 minutes.. Therefore, it is to your benefit to arrive a few minutes in advance of the appointment time. Since your social worker has sessions scheduled after yours, the sessions must end 45-50 minutes after the appointment time regardless of your arrival time (full fee for the session will be charged).

4. FEES AND PAYMENT
We accept cash or check made payable to Julia Jay. A $20.00 service charge will be levied on all checks returned by a bank for insufficient funds. If any or all outstanding balances are not paid, ATOP reserves the right to release a client from future services.

5. INSURANCE
At this time I am not accepting insurance for any sessions unless otherwise agreed upon. Please not that you are responsible for payment and if your insurance company will reimburse you for our services, this is your responsibility.

6. CANCELLATIONS AND MISSED APPOINTMENTS
When an appointment is scheduled, that time is reserved for you. If the appointment is missed or canceled without sufficient notice, the social worker is unable to make use of that time. Please note that the reason for missing an appointment is not relevant to the cancellation fee being assessed. Therefore, sessions must be canceled 24 hours in advance or a cancellation fee of $20 will be charged..
We trust that your involvement within the ATOP Professional Services will be helpful and profitable to you. If you have any questions regarding these arrangements or other aspects of your relationship with us, please discuss them with Julia Jay personally.
This is to certify that I have read, understand, and have been given a copy of this document.

Patient’s Signature ______________________________________________ Date_______________

Additional Policies and Procedures
PRIVACY NOTICE OF ATOP THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) that prescribes legal duties and privacy practices to protect the privacy of your individual identifiable health information; this is, Protected Health Information (PHI), as that term is defined in the HIPAA regulations. ATOP is required to follow the terms of this notice until it is replaced. ATOP may make changes to the terms of this notice at any time. Upon your request, we will provide you with a copy of the current Notice. ATOP reserves the right to make the changes apply to your Information maintained in my files before and after the effective date of the new Notice. The following is a general description of how Federal and State law permits me to use and disclose your Information.
Purposes for which ATOP May Use or Disclose Your Mental Health Information with your Consent
ATOP may request your consent for the use and/or disclosure of your Information for treatment, payment or health care operations as described below:

• Treatment. ATOP with use and disclose your Information to provide, coordinate, or manage your mental health care and any related services. ATOP may disclose your Information to physicians, therapists, other mental health providers, or other health care providers who are treating you or assisting in your diagnosis, treatment, or recovery.

• Payment. Your Information will be used and disclosed, as needed, to obtain payment for your mental health care services. This may include certain activities that your health insurance plan undertakes before it approves or pays for the mental health care services we recommend for you, such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and utilization review activities. If more than one, third party payer is responsible for payment for your health care, ATOP may disclose your Information to more than one health plan and those health plans may share your Information with each other. Your Information may also be used and disclosed as needed to obtain payment for mental health care services rendered to you by other providers.

• Mental Health Care Operations. ATOP may use or disclose, as needed, your Information in order to support my delivery of mental health care services. ATOP may call you by name in the waiting room area. ATOP may use or disclose your Information, as necessary, to contact you to schedule an appointment or remind you of your appointment.

• Health Care Services. Your Information may be used and disclosed to contact you and to give you information about treatment alternatives or other health benefits and services that may be of interest to you.
Uses and Disclosures With Your Verbal Consent
Your Information may be disclosed to a family member, friend, or other person designated by you or as designated by the law, if you verbally agree.
• Uses and Disclosures with Your Written Authorization
Except as provided below, your Information will not be used for any non-routine purposes unless you give your written authorization to do so. If you give written authorization to use or disclose your Information for a purpose that is not described in this Notice, then, with certain exception, you may revoke it in writing at any time. Your revocation will be effective for the Information ATOP maintains, unless ATOP has taken action in reliance on your authorization.

You have an option: you can either risk losing your spot or by another client. This would mean that in order to reschedule, you would need to take another spot.

If you opt not to pay the cancellation fee, we will consider your spot to be an open spot that could be filled by another client. This would mean that in order to reschedule, you would need to take another spot.

If you choose to pay the cancellation fee, your spot would automatically be reserved for you.

• Note: Everything on this form pertains to keeping your normal spot. If you cancel with less than 24 hours notice, the cancellation fee always applies.

I, ___________________________, have read the ATOP Financial/Scheduling Policy in its entirety and agree to it.

Date: ______________________

Signature: __________________________________

Consent For Treatment of a Minor

I, _________________, give A Touch of Peace and Julia Jay LSW Social Worker     Permission to provide treatment for _____________________________________.

Both parents must legally sign if custody of child  is shared

Confidentiality Statement

I, ________________, and _________________ understand limits to confidentiality and have
parent child been provided with a copy of this statement.

For the Parent/Guardian: The right to confidentiality is maintained with two exceptions:
1. The professional has reason to believe that you will harm yourself.
2. The professional has reason to believe that you will harm others, including your child.
For the Child: The right to confidentiality is maintained with three exceptions:
1. The professional has reason to believe that you will harm yourself.
2. The professional has reason to believe that you will harm others.
3. The professional has reason to believe that someone or something is harming you including your parents.
Additional Disclosures at the Parent’s Request:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________ ____________________________ ________
Therapist Parent/Guardian Date

________________________________________
Child

Disclosure Form
(to be completed at the first session with your social worker)

I, _________________________, am glad that you have chosen to begin a professional relationship with me. I am committed to providing the best possible care to promote your well-being and growth. My education is Master of family social work MSW, my credentials are Licensed Social worker LSW.

To contact me, please call 717-484-1253. Messages received after 6 p.m. may not be heard until the next day. Messages received over the weekend may not be heard until the next working day.

While your call is very important to me, I am often in session and may not immediately return your call. However, I will make every attempt to return it within 24 hours. If you have a clinical emergency, please do not call me first. Instead, please call 911 or go to the nearest emergency room while you attempt to reach me.

Sincerely,

Counselor’s
Signature___________________________________ Date ______________

This is to certify that I have read, understand, and have received a copy of this disclosure form: