Adolescent Client Intake Questionnaire - Restorative Healing Counseling & Psychotherapy

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General Information

Form Submission Date

Whom May We Thank for Referring You?

Form User Email

Enter Email Confirm Email

We use this to send confirmation

Name*

First Last

Nickname

Gender

Birth Date*

Age

Client’s Grade in School

Mother’s Name

First Last

Father’s Name

First Last

Client's Address*

Street Address City State / Province / Region ZIP / Postal Code

Additional Address (if Applicable)

Street Address City State / Province / Region ZIP / Postal Code

Mother’s Cell Phone

Father's Cell Phone

Mother’s Alternate Phone

Father’s Alternate Phone

Mother’s Work Phone

Father’s Work Phone

Mother’s Email

Father’s Email

Client’s Phone

Client’s Email

Consent to Email and/or Text Message

May we text you?(check for yes)

Mother’s cell

Father’s cell

Client's cell

May we leave a message?

Mother’s cell

Father’s cell

Client's cell

Mother’s work

Father’s work

May we contact you via Email?

Mother’s email

Father’s email

Client's email

Email

Email is not our preferred means of communication, and we do not routinely email with clients except under certain circumstances, under mutual agreement, to transmit specific documents. We do not respond to clinical matters (e.g., you are having a problem you want to discuss) via email. If you have a clinical matter to discuss with us, we ask that you call us so we can discuss it over the phone or wait until your next therapy session. If you would like for us to have the option of emailing you regarding business matters and/or to transmit documents, please consent by checking the corresponding box(es) above.

Text Messaging

Communication via text will only be used for the purposes of appointment reminders, scheduling and business matters that may arise. We will not text with you about any clinical matters. Text messaging is not a HIPAA compliant form of communication, which means that your privacy is at risk when texting. Because of this, we will only initiate texts or respond to texts with your consent. If you choose to check any of the corresponding boxes above, this will serve as your consent. If you have not checked yes above, we will not respond to texts from you. If you choose to consent to text, this will be only for the purposes of appointment reminders, scheduling, and business matters as stated above. If you send us a text regarding any matter other than scheduling or the business aspect of your treatment, we will only respond by calling you on the phone.
It is your choice whether or not to consent to text. You also have the right to withdraw consent at any time.
If you choose to consent, you may text us anytime Monday – Friday, 8am – 8pm or Saturday, 8am-12pm regarding scheduling or business matters. We will do our best to respond to your texts via returned text or phone call within a timely matter during these hours. If you choose to text us regarding personal information concerning therapy, we will not respond with a text. We will only respond with a phone call when we are able to do so. If you are experiencing a life threatening emergency, call 9-1-1 or go to your nearest emergency room.

I(we) agree to the terms of email and text messaging.

Yes

Client's Race

Languages Spoken in the Home

Mother’s Occupation

Mother’s Highest Level of Education

Father’s Occupation

Father's Highest Level of Education

Emergency Contact

1st Contact

**In case of emergency, who should we contact first and second?**

1st Contact Phone

2nd Contact

2nd Contact Phone

Family Members

Please list family members (and others) who are currently living in the client’s home:

Name #1

Age #1

Relationship #1

Grade/Occupation #1

Name #2

Age #2

Relationship #2

Grade/Occupation #2

Name #3

Age #3

Relationship #3

Grade/Occupation #3

Name #4

Age #4

Relationship #4

Grade/Occupation #4

Name #5

Age #5

Relationship #5

Grade/Occupation #5

Please list immediate family members who do NOT live in the client’s home:

Name #6

Age #6

Relationship #6

Grade/Occupation #6

Name #7

Age #7

Relationship #7

Grade/Occupation #7

General Mental Health Questions

Please briefly describe the problem that brought you to our office.

Has your child ever been formally diagnosed with any mental illness/condition (i.e., Depression, Anxiety, Bipolar Disorder, ADHD, etc.)?

Yes

If yes, what have you been diagnosed with?

Has your child ever been to counseling in the past?

Yes

If yes, with whom? When?

Did he/she have a good experience with past counseling?

Does your child have a psychiatrist?

Yes

If yes, with whom? When?

Does your child have any past or current medical conditions/illnesses?

Yes

If yes, explain(medical/illness)

Is there a history of mental illness within the family (either formally diagnosed or suspected)?

Yes

If yes, explain(mental illness)

Please list current medications:

Medication 1

Taken for 1

Medication 2

Taken for 2

Medication 3

Taken for 3

Medication 4

Taken for 4

Please list any vitamins and/or supplements which he/she is currently taking:

To the best of your knowledge:

Has there been any alcohol intake? (if yes, please explain)

Has there been any marijuana usage? (if yes, please explain)

Has there been any illegal drug usage (cocaine, mushrooms, etc.)? (If yes, please explain)

Has there been any vaping or cigarette smoking? (if yes, please explain)

Do you believe your child has/had an alcohol or substance abuse problem? (if yes, please explain)

Are there any alcohol or substance abuse problems within the family? (if yes, please explain)

Please list frequency and amount of caffeine intake

How often does your child eat foods that contain refined sugar and/or refined flour (e.g., cookies, cake, ice cream, crackers, white bread, pretzels, sugary cereals, etc?

Do you believe your child has a problem with his/her eating habits? (if yes, please explain)

General Assessment Questions

Does your child receive special educational services in school?

Yes

Were there/are there any concerns with performance or behavior at school?

Yes

Has there been any difficulty sleeping?

Yes

Have there recently been any noticeable changes in eating habits or appetite?

Yes

Has there been any noticeable weight gain or weight loss recently?

Yes

Is the family experiencing financial problems?

Yes

Have there been any big changes recently (moving, death in the family, etc.)?

Yes

Have you noticed a decrease in your child’s motivation lately?

Yes

Does your child worry a lot?

Yes

Does he/she appear overly concerned with being judged by others?

Yes

Does he/she often appear irritable or become easily frustrated?

Yes

Does he/she have anger outbursts or dramatic mood swings?

Yes

Does he/she have difficulty completely tasks and/or turning in homework?

Yes

Has there been any legal involvement or any problems with the law?

Yes

Do you believe your child has ever experienced something traumatic?

Yes

Has he/she ever experienced physical abuse?

Yes

Has your child been repeatedly bullied in school?

Yes

Has he/she ever been sexually abused?

Yes

Do you have serious concerns about your child’s eating behavior?

Yes

Do you believe your child has a problem with alcohol or drugs?

Yes

Do you believe either parent has a problem with alcohol or drug abuse?

Yes

Risk Assessment Questions

(for the client to answer)

Are you currently having thoughts of suicide (within the last 24 hours)?

Yes

Have you ever had thoughts of suicide?

Yes

Have you ever attempted suicide?

Yes

Have you ever had thoughts about harming yourself in any way?

Yes

Have you ever deliberately harmed yourself in any way?

Yes

Do you ever have aggressive or violent thoughts?

Yes

Have you ever demonstrated aggressive or violent behavior in any way?

Yes

Have you ever had serious thoughts about harming others in any way?

Yes

Have you ever intentionally caused bodily harm to another person?

Yes

Has your child ever been hospitalized for psychiatric reasons?

Yes

If yes , when was your child hospitalized, which hospital, and for what reason(s)?

(parents should answer)

Support System

(for the client to answer)

How much support do you believe your child receives from family, friends, and/or other people in his/her life?

Great deal

Some

Little

None

Does your child believe in a Higher Power?

Do the parents believe in a Higher Power?

What religion or spiritual belief system has been taught by the parents?

How important is your religion/spiritual belief system to the parents?

How important is your religion/spiritual belief system to your child?

Additional Comments

Will you be using Insurance?

Self Pay

I have insurance

Insurance Information

Primary Insurance Company

Group Number

ID Number

Policy Holder's Name

Policy Holder's Address

Policy Holder's Date of Birth

Employer

Policy Holder's Occupation

Policy Holder's City

Policy Holder's State

Policy Holder's Zip

Policy Holder's Phone Number

Policy Holder's Relationship to Client

Client Signature Date*

Insurance authorization

Signature*

Insurance authorization

Credit Card Authorization

For your convenience, and to guarantee payment for services rendered, we request preauthorization of a major credit card.
I authorize Restorative Healing Counseling & Psychotherapy, LLC to keep my signature on file and to charge my credit card account listed below for deductibles and/or co-pays/co-insurance not collected at time of service, and for any current outstanding account balances over 30 days following insurance determination.
I authorize Restorative Healing Counseling & Psychotherapy, LLC to charge my credit card a $100.00 fee due to a missed appointment or a late cancellation (appointments cancelled with less than 24 hours notice). Please note that missed appointments and late cancellations will NOT be covered by insurance.
I understand that if my credit card is charged, I may be charged interest per my agreement with my credit card company. This interest can be substantial and the amount owed will increase with each partial payment to the credit card company if not paid in full.
I understand that this authorization is valid until I cancel the authorization through written notice to Restorative Healing Counseling & Psychotherapy, LLC or unless otherwise indicated.

Client Signature Date*

Credit Card Preauthorization

Last 4 digits on card*

Signature*

SERVICES AGREEMENT

PSYCHOLOGICAL SERVICES

The goal of psychotherapy is to resolve personal difficulties through gaining a deeper understanding of yourself and your role in the relationships you have with other people. A variety of treatment modalities are integrated into the therapeutic process to assist you in understanding yourself and your relationships on a deeper level as well as acquire new skills, attitudes, and behaviors. The intended outcome is to live a happier, more fulfilling, and more productive life. It is important for you to know that psychotherapy can be challenging and uncomfortable at times as you will likely be discussing difficult aspects of your life, which may lead to experiencing feelings of sadness, anger, frustration, loneliness, and helplessness. These uncomfortable feelings are often necessary in leading you to the outcome of better relationships, solutions to certain problems, and reducing overall distress.
During the first few sessions, your therapist will be evaluating your needs and will communicate their thoughts and impressions with you. We will give you an overall idea of what our work together will look like and recommend how frequently we feel you should attend therapy. The success of the therapeutic process also depends largely on the relationship between the client and the therapist, and we encourage you to consider this as we begin our work together. Therapy is a commitment of time, money, and energy, so it is important that you feel comfortable and connected with the therapist you choose. If you do not feel your therapist is a good fit for you, please feel free to discuss this with us and we will provide you with a referral to a therapist who may be a better match.

SESSIONS

Your first appointment is an initial evaluation, which typically lasts 60 minutes. If you and your therapist agree to continue working together, you will typically meet once every week or once every other week, depending on your needs, although you may decide to meet more or less frequently. These sessions will each last 55-60 minutes unless otherwise specified and will be scheduled at a time you and your therapist agree on.

TELETHERAPY

At Restorative Healing Counseling & Psychotherapy, LLC, we offer teletherapy sessions. Teletherapy provides clients with services from the comfort, safety, and privacy of their own home. For teletherapy sessions, we use HIPAA compliant platforms called Doxy.me and Ring Central. During teletherapy sessions, your therapist is in a private space to maintain your confidentiality. To further maintain your own confidentiality, we highly recommend that you, as the client, also conduct teletherapy sessions in a private space where no one else can hear your session. Utilizing earbuds or headphones is recommended.

CONTACTING US

You may contact us by phone at (847) 492-2121. We return voicemail messages during office hours. If you have a matter that is urgent, please indicate this in your message along with your phone number, and we will return your call at our first possible opportunity. However, if you are having a life-threatening emergency, you must call 9-1-1 or go directly to your nearest hospital emergency room. If you wish to communicate with your therapist via email or text, we will only do so if you indicated permission by checking for yes elsewhere in this document. Please refer to our terms of emailing and texting, also indicated elsewhere in this document.

PROFESSIONAL FEES

Our hourly fee is $175 for an Initial Evaluation and $150 for Individual and Family Therapy sessions.
We require a 24 hours notice to cancel an appointment. Missed sessions and sessions cancelled within less than 24 hours notice will be charged a fee of $100. Please keep in mind that insurance companies cannot be billed for missed sessions, so this fee will be charged to you directly.
In addition to our scheduled sessions, we may charge for other services you come to need at the rate of $150/hour, and we will prorate this cost if such services require work for periods of less than an hour. These services include report-writing, letters we are asked to provide, travel times for meetings you request we attend, phone conversations lasting more than 5 minutes, and any other services we may agree on.

PAYMENT POLICY

Payment for services is due at the time of service via cash, check, or credit card. Any check returned for insufficient funds will result in an additional $30 fee per occurrence. Adult clients and parents/guardians of minor clients are personally responsible for payment of services unless otherwise indicated, in which case signed consent will be needed for us to communicate with the person who is responsible for payment. This consent will be for us to communicate with the third party only in regards to payment.

INSURANCE COVERAGE

At Restorative Healing Counseling & Psychotherapy, LLC we are contracted in-network providers with BlueCross BlueShield – PPO, United Healthcare, Optum, and Cigna. We are out-of-network with all other insurance plans, but you are welcome to use your out-of-network coverage for therapy sessions with us. We utilize Redeemed Billing to handle all of our billing matters. We will gladly have Redeemed Billing verify your insurance coverage for therapy sessions, and they will bill your insurance company for our services. However, we cannot guarantee that your insurance will cover our services, so you should verify with your carrier that mental health outpatient services are covered and to what extent.
You are only expected to pay your deductible payment (if it applies) or co-pay at the time of service. If you are not using insurance, our full fee will be expected at the time of service.
If your insurance company denies payment for services, you are responsible for payment of those services. Fees not paid in a timely manner will result in discontinuation of services until the balance is paid in full.

LEGAL INVOLVEMENT

Our role in providing therapy does not include involvement in our clients’ legal matters. We will not serve as a witness for you in any litigation, including (but not limited to) divorce proceedings, child custody proceedings, personal injury matters, employment related matters, or any other matters that may bring you to court. By signing this agreement, you acknowledge that we will not be involved in any such proceedings. If we are served with a subpoena to testify, you will bear the legal fees of us having the subpoena quashed. If we are still required by court order to testify in regards to your legal matters, you will be expected to pay for all of our professional time, including preparation, attendance at any legal proceedings, and transportation costs, even if we are called to testify by another party. We charge $300/hour for such services.

LIMITS OF CONFIDENTIALITY

The information you share in therapy is confidential and will not be disclosed to a third party without your written consent. However, there are some exceptions as follows:

If you are in imminent danger to yourself or another person, we are legally obligated to report this and disclose any information necessary to keep you or the other person safe.

If you disclose information that leads us to suspect child abuse or elder abuse, we are legally obligated to report this.

If we receive a court order to release information, we are obligated to honor it.

PROTECTED HEALTH INFORMATION AND HIPAA

Protected Health Information (PHI) under federal law refers to any information regarding health status, provision of healthcare, or payment for healthcare. HIPAA (Health Insurance Portability and Accountability Act of 1996) is a governing body of rules that keeps your health information as confidential and protected as possible. However, it does allow healthcare professionals and associated organizations (such as insurance companies) to utilize certain PHI for purposes of carrying out services and payment of those services. For example, in order to bill your insurance company, We must provide them with your name, identifying information, and diagnosis. The insurance company is also required to follow HIPAA to ensure your health information stays as protected as possible and only necessary information (as previously mentioned) will be disclosed for the sole purpose of which it is intended. You should know we have a contract with a digital practice management company called TherapyNotes to do electronic billing, scheduling, and to keep electronic records. TherapyNotes is a HIPAA compliant organization. We also use Echo Billing Solutions, Inc. for all of our billing. Echo Billing Solutions will be handling your billing matters.

PROFESSIONAL RECORDS

The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in your clinical record. You have the right to a copy of your clinical record if you request it in writing. Because these are professional records, they may be misinterpreted or upsetting to untrained readers. For this reason, we recommend you initially review them in the presence of your therapist or have them forwarded to another mental health professional so you can discuss the contents. There will be a handling fee plus a fee per page for medical records.

MINORS & PARENTS

Parents of child clients under 12 years of age are legally allowed to examine their child’s treatment records. Parents of child clients between the ages of 12 and 18 cannot examine their child’s records unless the child consents. This also applies to parents giving consent for us to speak with a third party, such as another healthcare professional or school personnel. Children 12 years of age and older must provide written consent in addition to their parents for us to speak with a third party outside of our treatment. Children who are 12 years and older do have the right to confidentiality in treatment. However, we feel parental involvement is often crucial to the successful outcome of psychotherapy. Therefore, we will provide parents with general information about the progress of treatment and will disclose certain additional treatment information to parents with the child’s consent. If we feel your child is in danger or is a danger to someone else, we will notify parents immediately. Before giving parents any additional information, We will first discuss the matter with the child, if possible, and handle objections he/she may have in an appropriate manner, considering what is in the best interest of the child.

I certify that I have read the Services Agreement for Restorative Healing Counseling & Psychotherapy, LLC, understand the terms, and agree to abide by all its terms. I understand that I reserve the right to terminate treatment and/or obtain a second opinion at any time.

Signature*

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