Adolescent Intake Paperwork Logo

  • Child/Adolescent Intake Form

  • 48-Hour Cancellation Policy

  • We understand that emergencies come up, here is our cancellations policy:

    • There is no charge for the first missed appointment.
    • There is a $50 charge to the card on file for the second missed appointment.
    • The full session fee is charged to the card on file for the third and subsequent missed appointments.
    • If you miss 3 or more appointments, Evergreen Therapy Center may end your services because of a lack of treatment engagement.

  • Here are things you can do:

    • Problem-solve in advance with your therapist any challenges that could prevent you from attending. We’re here to support you.
    • Please do not schedule when you have other commitments that may force you to cancel, for example, an athletic event.
    • Let us know as soon as you miss an appointment and tell us why you missed. You may email, text, or call our office.

  • Sign below to indicate your understanding and acceptance of our cancellation policy.

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  • Comprehensive Intake Form

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  • In this meeting, the clinician gathered the client's psychosocial history, identified major problems for therapeutic intervention, established preliminary diagnoses, and explained the process of therapy. Clinician explored the nature of the presenting problems, the ways they affect the client, and changes desired by the client. The clinician also reviewed forms related to agency policy and procedures (HIPAA, billing, informed consent, psychotherapy contract, etc.). We needed the entire hour to effectively assess the client's concerns. The client was actively engaged and participated fully in this session.

    The responses in the psychosocial history are based on the client's self-report, unless otherwise noted.

  • FAMILY MENTAL HEALTH:

  • PHQ-9 (Depression)

  • Over the past 2 weeks, how much have you been bothered by the following problems?

  • 1-4 Minimal depression, 5-9 Mild depression, 10-14 Moderate depression, 15-19 Moderately severe depression, 20-27 Severe depression.

  • GAD-7 (Anxiety/Worry)

  • 0 to 4 minimal anxiety/worry, 5 to 9 mild anxiety/worry, 10 – 14 moderate anxiety/worry, 15 – 21 severe anxiety/worry.

  • Texting and Email Consent Form

  • This form gives Evergreen Therapy Center permission to text or email you about appointments and information regarding your care. If you do not wish to communicate by text or email, leave this form unsigned.

    Please note that email and texting is a convenient form of communication, but it is not a secure form of communication and confidentiality cannot be absolutely guaranteed. If this is a concern, please call 319-853-8762.

     

    I consent and give permission for my provider and other staff at Evergreen Therapy Center to communicate with me by email or text regarding various aspects of my care, which may include, but shall not be limited to, diagnoses, treatment plans, recommended interventions, appointments, and billing.

    I understand that email and text messaging are not confidential methods of communication. I further understand that, because of this, there is a chance that email and text messages regarding my care might be read by someone else.

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