"Change Happens Because Of A Caring and Listening Ear"

Name

Address

Date of Birth/Age

Phone Number

May we leave a message at the above number?

Yes
No

Email Address

May we leave a message at your email address? Email correspondence is not considered to be a confidential medium of communication.

Yes
No

Marital Status

Married
Single
Engaged
Divorced
Widowed
Separated

History: Have you previously received any type of mental health services (psychotherapy, psychiatric services,etc.)? If yes, previous therapist/practitioner: Are you currently taking any prescription medication? If yes, please list: Have you ever been prescribed psychiatric medication? If yes, please list and provide dates:

Referral Source:

Emergency Contact Name and Phone Number

Medical history: current medical problems; also any medical hospitalizations

Current medications; amount taken each day; name of the doctor

Mental health history: Have you ever attempted suicide? Are you currently thinking about hurting yourself or others

Are you currently self-administering any mental health medications? If so please list the names and who prescribes them and your diagnosis

Legal: Are you currently on probation/pretrial? If yes please write name, address, and fax number who information will go to

What is your current charge/s? Past legal charges.

Please write exactly what you have been ordered to do (if you do not know look on your court order or ask the person who has asked you to complete requirement)

Employer Name, Address, Your Job Title, and How Long There

Education: High Level of Education Completed

Substance Use: Do you currently drink alcohol or beer or use drugs?

Yes
No

If you do drink alcohol or beer or use drugs when was the last time you used drank or used drugs? How much beer or alcohol did you drink or drugs used?

How often would you say you drink alcohol or beer or use drugs?

History of abuse or trauma (i.e., physical, emotional, mental or sexual) If so please describe

What is your goal/s or what would you like to accomplish or see change as a result of engaging in therapy, education, or treatment?

User Agreement

INFORMED CONSENT AND CONSENT TO RELEASE INFORMATION

I hereby give Venerable Counseling Services, LLC or my therapist permission to share my attendance letter of enrollment, recommendations, progress reports, and certificate of completion to my referring party.

In additon, I understand that there are exceptions to confidentiality/HIPAA which are suspected child or elderly abuse; we believe you are a danger to self or others; you tell us you are going to harm yourself; harm someone else or damage their property; commit a crime on the property or against staff; court order signed by a judge; auditing purposes.

Today's Date