Client's Name (First, MI, Last) |
Preferred Name or Nickname |
DOB |
Age |
Gender |
|
Mailing Address
|
Physical Address (if different)
|
|
Email |
As a courtesy, we offer the option of appointment reminders by email, text or landline phone message. These messages are delivered 48-hours in advance.
These serve as reminders only & should not be relied upon exclusively. Please also be sure to note your appointment in your own personal calendars.
|
|
Emergency Contact Name |
Phone(s) |
Relationship |
Client Referred By |
Financial Information
I understand that I am responsible for charges incurred that are not covered by my insurance and that I am responsible for understanding my coverage and for knowing
when the limits of my coverage are being exceeded. I authorize the release of information necessary to file a claim with my insurance company, including electronically,
and assign benefits to Counseling Associates of New London, PLLC, Counseling Associates of Newport, Counseling Associates of Claremont & and Counseling
Associates of The Upper Valley.
A copy of this signature is as valid as the original. We have a standard 24-hour cancellation policy. Please notify your therapist as
soon as you know you will be unable to keep an appointment and at least 24 hours, preferably 48 hours, in advance of the scheduled time. The policy of this office is to
charge $60 for those missed sessions not canceled with 24 hours’ notice. Insurance companies will not pay for sessions that you miss, and it would be fraudulent for
us to submit a claim for missed sessions.
|
Signature |
Date |
Primary Insurance Company
|
Secondary Insurance Company
|
ID#
|
Group#
|
ID#
|
Group#
|
Please provide the insurance card(s) for copying at the time of appointment. Responsible party to whom statements will be sent if different from Client. |
Mailing Address
|
Phone
Relationship
|
|
Consent to Treatment
I acknowledge that I have received, have read (or have had read to me), and understand the Information for Clients brochure (available on the website or in office) that includes:
- Counseling Associates Practice Information
- CA Cancellation Policy
- Notification of Privacy Policies Regarding Protected Health Information (PHI)
- NH Mental Health Bill of Rights
I understand the information about the therapy I am considering. I have had all my questions answered to my satisfaction.
I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist and that, as with any treatment, there are some
risks as well as many benefits with therapy. I am aware that I may stop my treatment with this therapist at any time. I understand that I will still be responsible for paying for the
services I have already received. I understand that there may be consequences to such a decision outside of my therapist's control
(e.g. if my treatment has been court-ordered, I will have to respond to the court).
My signature below indicates that I understand the information about the therapy I am considering, and I have had all questions answered to my satisfaction. I agree to abide by the
terms outlined throughout my professional relationship with Counseling Associates of New London, PLLC, which includes Counseling Associates of New London, Newport,
Claremont & the Upper Valley. I consent to receive services from Counseling Associates & I agree to take an active role in my own treatment.
|
Information | |
|
|
|
|
If yes, please note the name of therapists and approximate dates.
|
Health Information | |
Primary Car Provider |
Date of Last Physical |
Other Providers |
|
Allergies |
No known drug allergies |
Current Medications | |
Medication | Dosage |
Medication | Dosage |
| |
| |
| |
| |
| |
| |
Substance Use | |
|
How many drinks containing alcohol do you have in a typical day? |
|
How much? |
Other substances used |
Frequency |
Are you concerned about your
|
Physical Health Issues
|
Mental Health or Substance Abuse Treatment History, including hospitalizations
|
|
|
Signature of client (or person acting for client) |
Date |
Printed Name |
Relationship to Client |