New Client Therapy Intake Form

In a few words, describe the following as it pertains to your life in the past month:

Please check the feelings that apply to you in the past month:

Office Policy and Informed Consent

Confidentiality

Any information you reveal to me is considered private and it is your right to have that information kept confidential. The exceptions to the limits of confidentiality are as follows: (1) you consent in writing to release information (2) the life or safety of you or someone else is threatened (3)disclosure is required by law*.

Hours and Emergencies

I can be reached during regular business hours Monday through Friday and typically return calls within 48 hours. When I am out of town, I will make arrangements for another therapist to cover crisis calls. Text messages and emails are not guaranteed to be secure and are used to discuss scheduling only. In the event of an emergency, and I can not be reached quickly, you may call your family physician, the Sacramento County Emergency Crisis Line at 916-875-1000, or 911.

Therapeutic Risk

While it is anticipated that therapeutic services will be helpful to you, there is the possibility that you will experience some life disruption and emotional distress. You are free to discontinue treatment at any time.

Physical Examination

We strongly recommend that each client obtain a thorough physical exam prior to commencing therapy. This is especially important if you are suffering symptoms of anxiety or depression, headaches, and/or weight gain/loss. Symptoms may be biologically caused or may be there for a protective reason.

Payment

Fees are payable at the time of your appointment to Conscious Path Therapy unless other arrangements have been made in advance. You are responsible for payment of services received even if insurance is billed. At this time, insurance will not be accepted or billed through Conscious Path Therapy. If special arrangements are made for assignment of benefits, you are responsible for any deductible or copayment at the time of your appointment. There is a fifteen-dollar ($15.00) service charge for all checks returned by the bank.

Cancellation and Missed Appointments

Your appointment time is reserved for you. Without 24 hour cancellation notice, you are responsible for full payment of the missed or late cancel appointment at your session rate. Insurance companies can not be billed for missed or late cancel appointments, and you are solely responsible for paying the charge of the scheduled appointment. *Additional fees are associated.

ACKNOWLEDGEMENT OF RECEIPT OF OFFICE POLICY AND INFORMED CONSENT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices, Office Policy, and Informed Consent that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information, payment, and office policy. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at 916-804-4471. If you have any questions about my Notice of Privacy Practices, please contact Erin Miguelgorry at: Folsomtherapy@gmail.com. I acknowledge receipt of the Notice of Privacy Practices of Conscious Path Marriage and Family Therapy, Inc.

Private Payment for Therapy

Therapist is an out-of-network provider. Therefore, all services will be paid directly to the therapist by the client at the time of session. A “Super-bill” for reimbursement from your insurance company can be provided only if agreed upon ahead of time. Services may be covered in full or in part by your health insurance company or employee benefit plan depending on your individual coverage. You are responsible for payment for all services rendered either by check, cash, or credit card at the agreed upon rate of $____________ per session. All checks will be paid to Conscious Path Therapy

No-shows or cancellations under 24 hours will also be charged at the full session rate.

"No Secrets" Policy

This written policy is intended to inform you, the participants in therapy, that when I agree to treat a couple or a family, I consider that couple or family (the treatment unit) to be the patient. For instance, if there is a request for the treatment records of the couple or the family, I will seek the authorization of all members of the treatment unit before I release confidential information to third parties. Also, if my records are subpoenaed, I will assert the psychotherapist-patient privilege on behalf of the patient (treatment unit). During the course of my work with a couple or a family, I may see a smaller part of the treatment unit (e.g., an individual or two siblings) for one or more sessions. These sessions should be seen by you as a part of the work that I am doing with the family or the couple, unless otherwise indicated. If you are involved in one or more of such sessions with me, please understand that generally these sessions are confidential in the sense that I will not release any confidential information to a third party unless I am required by law to do so or unless I have your written authorization. In fact, since those sessions can and should be considered a part of the treatment of the couple or family, I would also seek the authorization of the other individuals in the treatment unit before releasing confidential information to a third party. However, I may need to share information learned in an individual session (or a session with only a portion of the treatment unit being present) with the entire treatment unit – that is, the family or the couple, if I am to effectively serve the unit being treated. I will use my best judgment as to whether, when, and to what extent I will make disclosures to the treatment unit, and will also, if appropriate, first give the individual or the smaller part of the treatment unit being seen the opportunity to make the disclosure. Thus, if you feel it necessary to talk about matters that you absolutely want to be shared with no one, you might want to consult with an individual therapist who can treat you individually. This “no secrets” policy is intended to allow me to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or the family. If I am not free to exercise my clinical judgment regarding the need to bring this information to the family or the couple during their therapy, I might be placed in a situation where I will have to terminate treatment of the couple or the family. This policy is intended to prevent the need for such a termination. We, the members of the couple/family or other unit being seen, acknowledge by our individual signatures below, that each of us has read this policy, that we understand it, that we have had an opportunity to discuss its contents with Erin Miguelgorry, LMFT (the therapist), and that we enter couple/family therapy in agreement with this policy.