New Client Profile – Counseling

"*" indicates required fields

Contact Information

First Name*

Last Name*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Insurance Carrier*

Insurance ID#*

Emergency Contact*

Name

Phone

Personal Information

What concerns bring you into counseling?*

On a scale of 1-10, indicate how stressful this problem is for you.

Is this a new problem or has this been a problem in the past? When?*

Is this problem impacting your work or school life? Your social life? Relationships? Your daily functioning?*

What are your goals for therapy?*

What do you want to have happen as a result of therapy?*

Have you seen a therapist in the past? When? Did you find it helpful?*

Who do you turn to for support?*

List everyone who lives in your home, including their age and relationship to you.*

Name

Age

Relationship

List all doctors or other healthcare practitioners, you see on a regular basis.*

Please provide their contact information and sign the following release if I will be coordinating care with them: Mutual Exchange of Information

Describe any current medical problems.*

What medications, supplements and herbs do you take currently?*

What medical concerns have you had in the past, including serious illnesses or injuries?*

Please list any substances you use currently in any amount, including beer, liquor, wine, marijuana, tobacco, or street drugs.*

Substance

Amount

Has substance use ever caused problems for you in the past?

How many times a week do you engage in exercise / movement? This includes walking, jogging, workouts, exercise classes, yoga, dancing, etc.*

In a few words, describe your relationship with food.*

What is your occupation and place of work?*

On a scale of 1-10, how do you rate your level of job satisfaction?

How important is faith or spirituality for you? Please explain.*

Authorizations

Consent for Treatment

Consent for Treatment:*

I hereby give my consent to my clinician, Rebecca K. Lowry, MA, LCMHC (N.C. license #4137) to provide evaluation, treatment and/or other services that we may mutually determine to be appropriate. I understand that services will be rendered in a professional manner, consistent with accepted ethical standards.
I understand that I will likely gain the most benefit from counseling if I am committed to the process and attend regularly. I also understand that it is not uncommon, over the course of therapy, to temporarily experience increased distress. This is an indicator that important work is underway and significant changes are beginning. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.
I acknowledge that I have received and read the Office Policies sheet and the HIPAA information. I understand that I may ask questions at any time about any of the information given to me, and about treatment options.
I understand that the fee for the initial assessment is $140, and fee for subsequent sessions is $100 for a 45-minute session and $130 for a 55-60-minute session. Several insurance providers and other referral sources with funding are accepted for payment. I have read the office policies and fee schedule and understand that I must cancel an appointment at least 24 hours before the scheduled time. Otherwise, I will be financially responsible for the full fee for the session. Payment will be due and payable to the therapist at the beginning of each session unless other arrangements have been negotiated. Please come prepared to pay by cash, check, or credit/debit card.
I understand that if I do not make payment for services, the therapist may discontinue treatment.
I understand that I may discontinue my involvement in therapy at any time. If I choose to do so, I will inform my counselor of my decision.
Due to the typical work schedules of counselors, I understand that it may take my counselor up to 48 hours to return a phone call. If at any time during treatment I cannot wait for a return call from my counselor, I agree to contact my psychiatrist, family physician, or go to the nearest emergency room.

I agree to the terms listed above.

Consent for Treatment of Children and Adolescents:

Minor Child's Name:

Signature

Signature*

By signing this form, you are agreeing that all information is true to the best of your knowledge.

CAPTCHA

Date*

Phone

This field is for validation purposes and should be left unchanged.