Patient Intake Form

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insurance*
Insurance Number*
Name of Secondary Insurance *

Enter nameEnter insurance ID #
Contact Number*
Contact Email*
Emergency Contact

Area CodePhone Number
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can.*
What are your goals for counseling?*
Best way to contact you*
Have you seen a mental health professional before?*
Specify all medications and supplements you are presently taking*
If taking prescription medication, who is your prescribing MD? Please include the type of MD, name and phone number.*
Who is your primary care physician? Please include type of MD, name and phone number.*
Do you drink alcohol?*

YesNo
Do you use recreational drugs?*

YesNo
Do you have suicidal thoughts?*

YesNo
Have you ever attempted suicide?*

YesNo
Do you have thoughts or urges to harm others?*

YesNo
Have you ever been hospitalized for a psychiatric issue?*

YesNo
Please check any of the following you have experienced in the past six months*

Increased appetiteDecreased appetiteTrouble concentratingDifficulty sleepingExcessive sleepLow motivationIsolation from othersFatigue/low energyLow self-esteemDepressed moodTearful or crying spellsAnxietyFearHopelessnessPanicOther
Please check any of the following that apply*

HeadacheHigh blood pressureGastritis or esophagitisHormone-related problemsHead injuryAngina or chest painIrritable bowelChronic painLoss of consciousnessHeart attackBone or joint problemsSeizuresKidney-related issuesChronic fatigueDizzinessFaintnessHeart valve problemsUrinary tract problemsFibromyalgiaNumbness & tinglingShortness of breathDiabetesHepatitisAsthmaArthritisThyroid issuesHIV/AIDSCancerOther
What else would you like me to know?*
When would you like to begin your sessions?*

MonthDayYear
Date
Which form of therapy do you prefer?*

In Person/At HomeVideo ChatAudio
Complete the sentence. I am most happy when…*
INFORMED CONSENT
Dear Patient.

At Doppler Psychology Services, we design a program in mental wellness therapy specifically to fit your needs. Your program may involve the use of many different types of evaluations and treatments as well as a variety of procedures to help try and improve your function. As with all forms of medical treatment, there are both benefits and risks involved with mental wellness therapy.

Since the response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain therapy intervention or procedure. Doppler Psychology cannot guarantee that your treatment will help the condition which you are seeking rehabilitation for. Treatments may also aggravate previously existing conditions as well as cause additional discomfort.

Please make sure to discuss with your Therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also wish to discuss the potential risks and benefits of a specific treatment. If at any time you become uncomfortable with your treatment, please notify your therapist: whether it is before, during or after your session.

Confidentiality - The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

I acknowledge that my treatment program has been explained by Doppler Psychology Services, and all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Mental Wellness Therapy as outlined to me and I wish to proceed.
Patient Name*

First NameLast Name
Patient Signature*

Clear
Date

MonthDayYear
Date
Guardian Name (if patient is under 18)

First NameLast Name
Guardian Signature

Clear
Date

MonthDayYear
Date
Release of Information Consent
Client's Name

First NameLast Name
* I authorize Doppler At Home Therapy to:

SendReceive
The Following Information

Medical history and evaluation(s)Mental health evaluationsDevelopmental and/or social historyEducational recordsProgress notes, and treatment or closing summaryOther
To / From
Phone Number

Area CodePhone Number
Your relationship to client:*

SelfParent/legal guardianPersonal representativeType option 4Other
* The above information will be used for the following purposes:

Planning appropriate treatment or programContinuing appropriate treatment or programDetermining eligibility for benefits or programCase reviewUpdating filesOther
I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization. If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.
Signature

Clear
Date

MonthDayYear
Date
Witness signature (if client is unable to sign):

Clear
Witness Date

MonthDayYear
Date
TELEHEALTH CONSENT FORM
1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions,
unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

INFORMED CONSENT

Release of Information Consent

TELEHEALTH CONSENT FORM