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CONTACT US TO SCHEDULE AN APPOINTMENT
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Ravenswood Therapy Group
Home
Services
Therapists
FAQ’s
About Us
Contact
Forms
Client Intake Form
Patient Name:
(Required)
First
Last
Home Phone:
Work Phone:
Cell Phone:
(Required)
Email:
(Required)
Address:
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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Idaho
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Indiana
Iowa
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Louisiana
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Maryland
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Northern Mariana Islands
Ohio
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South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth:
Month
Day
Year
Reason for seeking therapy:
Primary Care Physician:
First
Last
Phone:
Psychiatrist:
First
Last
Phone:
Are you on any medications?
Yes
No
Medications:
Emergency Contact:
(Required)
First
Last
Phone:
(Required)
Relationship to Client:
(Required)
Insurance
Coverage Provider:
Identification Number:
Group Number:
Subscriber:
First
Last
Date of Birth:
Month
Day
Year
Employer:
Relationship to client:
Self
Spouse
Other
Client/Therapist Agreement
SERVICES:
The therapist agrees to provide psychotherapy services to the client. These services may include individual, couple, or family therapy as well as any other services that are recommended by the therapist. Any recommendations for treatment will thoroughly be discussed with the client.
CONFIDENTIALITY:
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without your written permission. Exceptions required by law and ethics include: Any suspected abuse or neglect of dependent adult, children and elderly person, require that the information is reported to the appropriate authorities immediately. If a person intends to harm himself/herself, make every effort to develop a plan that insures safety. Otherwise every effort will be made to ensure your safety e.g. contacting emergency services. If a client is threatening serious bodily harm to another person(s), law requires that the intended victim is informed immediately.
FEES:
The client agrees to pay a therapist for services at the time of service (unless another arrangement is made between the client and therapist). Fees are subject to change, however, a client will be given a one-month notice.
CANCELLATION POLICY:
24 hours' notice is required when canceling or changing an appointment.
Without 24 hours' notice, the client will be responsible to pay for the session. This means that client will be responsible for the full amount of the agreed-upon fee or, the client’s insurance company’s “allowed amount,” as a missed session cannot be billed to the insurance company.
EMERGENCIES:
If a client needs to talk to a therapist immediately, the client must ensure that his/her message indicates such urgency. The client will be contacted as soon as possible. However, in case of life-threatening emergencies, the client must call 911 or his/her local emergency number.
Consent
(Required)
I agree to the Ravenswood Therapy Group agreement.
Date
(Required)
Month
Day
Year
Signature
(Required)
Name
This field is for validation purposes and should be left unchanged.
