INTAKE FORM

Today’s Date _______________

Your Name ______________________________________________________ Date of Birth _______________
Spouse’s/Partner’s Name (if applicable) ____________________________________ Date of Birth _______________
Complete Street Address _______________________________________________________________________
Mailing Address (if different from Street Address) ___________________________________________________
Home Telephone _____________________________________ Can we leave a message at this number?  Yes  No
Other Telephone _____________________________________ Can we leave a message at this number?  Yes  No
E-Mail Address ______________________________________________________________________________
Emergency Contact (name, relationship, telephone) ___________________________________________________
	Can we leave a message at this number?  Yes  No
Ex-Spouse’s/Partner’s Name (if applicable) __________________________________ Date of Birth _______________
Complete Street Address _______________________________________________________________________
Mailing Address (if different from Street Address) ___________________________________________________
Home Telephone _______________________________ Other Telephone _______________________________ 
What challenges are you seeking help for (e.g., depression, marital problems, pornography, etc.)?
__________________________________________________________________________________________
Have you sought or received help from a mental health professional before?  Yes   No
If you answered “Yes,” please briefly describe the situation (e.g., when, where, why, duration):  
__________________________________________________________________________________________
__________________________________________________________________________________________
Family Information (spouse, all children, and any others who live in your household)
Name								Age			Relationship	_______	
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list any medications and/or medical conditions/concerns that we should be aware of:
__________________________________________________________________________________________
__________________________________________________________________________________________
Will a third party (e.g., family member, clergy) be covering part/all of the costs of counseling?  If so, please list the third party’s name and telephone number: _____________________________________________________________
How were you referred to us? ____________________________________________________________________
May we contact this person to thank them for their referral?  (Initial here) _____ Yes  _____ No

My signature below affirms that I have read, understood, and signed all intake documentation and that I give my informed and voluntary consent to enter therapy (and/or to have my child/ren enter therapy).  I affirm that I have read and understood the policy regarding Minor Children and that I have provided true, accurate and current information regarding parental/family status and parental authority regarding any minor child participating in counseling sessions.  I affirm that prior to becoming a client of Riverdale Counseling Center, Inc., I was given sufficient information to understand the nature of counseling, including the possible risks and benefits.  I understand the Informed Consent and Disclosure, Confidentiality, and Office Policies documents which I have signed.  I have had an opportunity to ask questions and have had my questions answered satisfactorily.  I understand that I can ask questions and raise concerns about the treatment at any time.  

__________________________	______________________________		______________________________
Client Signature									Date
[Attach copy of driver’s license.]
INSURANCE INFORMATION

Client’s Full Name: ___________________________________________Date of Birth: __________________
Complete Street Address: ____________________________________________________________________
Mailing Address (if different from Street Address): ________________________________________________
Home Telephone: _______________________________ Can we leave a message at this number?  Yes  No
Other Telephone: _______________________________ Can we leave a message at this number?  Yes  No
E-Mail Address: _______________________
Marital Status:  Married    Divorced    Single		Social Security Number: ___________________________

Spouse or Other Responsible Party: ___________________________________________________________ 
Relationship to Client: ________________________________________   Date of Birth: __________________
Complete Street Address:  ____________________________________________________________________
Mailing Address (if different from Street Address):  ________________________________________________
Home Telephone: _______________________________ Can we leave a message at this number?  Yes  No
Other Telephone: _______________________________ Can we leave a message at this number?  Yes  No
E-Mail Address: ____________________________   Social Security Number: ___________________________

Financially Responsible Party (if Client is minor): ________________________________________________
Relationship to Client: ________________________________________   Date of Birth: __________________
Complete Street Address:  ____________________________________________________________________
Mailing Address (if different from Street Address):  ________________________________________________
Home Telephone: _______________________________  Can we leave a message at this number?  Yes  No
Other Telephone: _______________________________  Can we leave a message at this number?  Yes  No
E-Mail Address: _____________________________   Social Security Number: __________________________

Emergency Contact (name, relationship, telephone): _______________________________________________
	Can we leave a message at this number?  Yes  No
E-Mail Address: ________________________________

Name of Primary Insured: _____________________________________  Date of Birth: ________________
Social Security Number (if other than above): _________________________

Authorization to Release Information and Assignment of Benefits

Authorization is hereby granted to release to my insurance company(ies) of record such information as may be necessary for the completion of my claims.  I understand that I am financially responsible for charges not covered by insurance and assign any insurance benefits to Riverdale Counseling Center, Inc.  I also request payment of government benefits to Riverdale Counseling Center, Inc.  

Signature of Client(s): ________________________________________		Date: ________________________

If the Client is a minor, at least one Parent/Guardian must sign, although both parents are financially responsible.

Signature of Parent/Guardian: ___________________________________	Date: ________________________

[Attach copy of front and back of insurance card(s).]

INFORMED CONSENT/DISCLOSURE

Welcome to our practice.  We provide the following information to help establish the clarity, understanding, and trust essential to a therapeutic relationship.  Please read the following information carefully, as it contains important information about our practice and policies.  Note any questions or concerns you have, and we can discuss them before beginning counseling.  After you initial each paragraph and sign this document, it will constitute a binding agreement between us.
  
The Process of Therapy/Evaluation:  Participation in counseling can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek help.  As a collaborative process, therapy requires your very active efforts, honesty, and openness in order to achieve desired changes.  We will periodically ask for your feedback on counseling and will expect you to respond openly and honestly.  _____

During evaluation or counseling, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, and so forth.  We may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed.  Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended.  _____

Counseling may also result in decisions about making many different kinds of changes.  Sometimes a decision that is positive for one family member is viewed negatively by another family member.  Change will sometimes be easy and swift; other times it will be slow and even frustrating.  There is no guarantee that counseling will yield the intended results.  _____

Sometimes more than one approach can be helpful in dealing with a certain situation.  You are entitled by law to receive information about the methods of therapy, the techniques used, the duration of counseling, if known, and the fee structure.  During the course of counseling, we are likely to draw on various therapeutic approaches according, in part, to the problem that is being treated and our assessment of what will best benefit you.  Our approach tends to be client centered and family systems oriented.  At times, we may draw on other approaches.  Within a reasonable period of time after the initiation of treatment, we will be able to offer you some initial impressions of what our work will include.  You should also make your own assessment about whether you feel comfortable working with us.  If you have any questions about the process of counseling, please let us know.  We will always seek to answer your questions fully.  _____

Ending Counseling:  The most common reason for ending counseling is that a client’s concerns have been addressed to their satisfaction.  Although you are free to end counseling or seek a second opinion from another counselor at any time, most clients find it helpful to have one or two “ending/termination sessions” to bring closure to counseling and discuss what has taken place during our time together.  These “ending sessions” can be helpful in preventing future problems.  Another scenario in which counseling ends is when a client’s challenges lie beyond the limits of our expertise or ability to help.  We do not work with clients whose challenges, in our opinion, are beyond our ability.  If this becomes apparent to us at any point, we would discuss this with you, offer you appropriate referrals, and end treatment.  _____

Legal Disclosures:  As to the regulatory requirements applicable to mental health professionals, a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master’s degree in their profession and have two years of post-master’s supervision.  A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision.  A Licensed Social Worker must hold a master’s degree in social work.  A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.  A Certified Addiction Counselor I (CACI) must be a high school graduate, and complete required training hours and 1000 hours of supervised experience.  A CACII must complete additional required training hours and 2000 hours of supervised experience.  A CACIII must have a bachelor’s degree in behavioral health, and complete additional required training hours and 2000 hours of supervised experience.  A Licensed Addiction Counselor must have a clinical master’s degree and meet the CACIII requirements.  A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.  See the attached sheet for  credentials of the psychotherapists at Riverdale Counseling Center.  _____

Both personally and professionally, we are committed to the highest standards of ethical practice in our field.  The information provided by clients during therapy sessions is legally confidential, except as provided in Section 12-43-218 of the Colorado Mental Health Statute, and except for certain legal exceptions that are identified in our Confidentiality form.  In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.  The practice of psychotherapy in Colorado is regulated by the Mental Health Section of the Division of Registration.  If you should have a complaint about unethical conduct, you may contact the appropriate board at 1560 Broadway, Suite 1350, Denver, CO  80202, (303) 894-7800.  _____

I have read the preceding information, it has also been provided verbally, and I understand my rights as a client/patient.  

Client Signature: _______________________________________________________	Date: _________________________

Counselor Signature: ____________________________________________________	Date: _________________________

Keep this page for your records.

By law, all counselors in Colorado are required to disclose their credentials and degrees.  Riverdale Counseling Center, Inc. counselors, their credentials and degrees, are as follows:  

Margaret Zappitello, M.A., LPC, CACIII:  
•	Licensed Professional Counselor in the State of Colorado (License #2536) 
•	Certified Addiction Counselor III in the State of Colorado (License #7062)
•	M.A. in Counseling Psychology and Counselor Education, Marriage and Family Therapy Track
•	B.S. in Child Development and Family Relationships

Valerie Bye-Wolfe, R.N., M.A., LPC:
•	Licensed Professional Counselor in the State of Colorado (License #10920)
•	Diploma in Nursing
•	B.A. in Organizational Management
•	M.A. in Counseling

Jackie Sierra, M.A.:
•	Registered Psychotherapist in the State of Colorado (#7352)
•	B.S. in Business Administration 
•	M.A. in Psychology

Kevin Palmer, M.A.
•	Life Coach
•	B.S. in Business Management
•	M.A. in Marriage and Family Therapy

Jolie Roach, M.A.:
•	Registered Psychotherapist in the State of Colorado (#13818)
•	B.S. in Business Administration
•	M.S. in Management
•	M.A. in Professional Counseling

CONFIDENTIALITY

Trust is the foundation of a good therapeutic relationship.  We strive to provide a safe atmosphere where you can honestly explore very personal issues.  All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.  You should be aware of the following issues about confidentiality.

Consultation and Video Recording of Sessions:  In order to provide the best possible counseling treatment, it is common for counselors to periodically record video of sessions; we make particular use of this when working with couples.  The purpose of recording counseling sessions is to enhance the effectiveness of counseling by providing us with another way to review sessions.  We also consult regularly with other professionals concerning our clients; this consultation sometimes includes reviewing recorded portions of counseling.  This practice of consultation often enhances the effectiveness of counseling as “two sets of eyes are often better than one.”  All professionals with whom we consult are bound by the same laws respecting your confidentiality.

Consultation with Psychiatrists:  If you are also begin seen by a psychiatrist, it is our policy to require an authorization for us to exchange information regarding your medical and mental health treatment.  If this is not a suitable arrangement for you, we will offer referrals to you to be seen in a different practice.

Some of the circumstances where disclosure is required by the law are as follows:

•	There is a reasonable suspicion of the abuse or neglect of a child, dependent, or vulnerable adult.  A report will be made to appropriate protective agencies.

•	When you present/threaten grave bodily harm to others or to property.  We have a legal duty to warn those threatened, and to contact law enforcement.

•	When you are actively suicidal or threaten significant bodily harm to yourself.  We have a duty to obtain help from others to do what is necessary to keep you safe.

•	Disclosure may be required pursuant to legal proceedings.  If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain counseling records and/or testimony from Riverdale Counseling Center, Inc.  Also, if you are on probation/parole, it may be legally required that we share information with various individuals appointed by the courts.

In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.  We will use clinical judgment when revealing such information.  If you reveal a “secret” that you refuse to disclose to the others and that puts us, by knowing the “secret,” in a position of hurting an honest relationship with others in the couple/family, we will terminate the therapy.  We will not release records to any outside party unless authorized to do so, in writing, by every member of the couple or family in treatment able to execute a waiver.

If we see a child under the age of consent (younger than 16), all custodial parents have a right to information shared in the session.  Custodial parents should be aware that exercising this right may be detrimental to the therapeutic process, and so may wish to allow confidentiality between the child and counselor.

Considering all of the above exclusions, upon your request we will release information to any agency/person you specify unless we conclude that releasing such information might be harmful.

There is the possibility that you may see someone you know in the waiting room or cross paths with us while out in the community.  Although we may greet you cordially, we never acknowledge working therapeutically with anyone without their written permission.

By signing below, I affirm that I have read and understand the nature of confidentiality in therapy as set forth above.  I also give my consent to allow my therapy sessions with Riverdale Counseling Center, Inc. to be recorded by video.  I understand that any supervisor, counselor, or counselor-in-training who observes the recording of my therapy session is under the same confidentiality requirements as my counselor.  Furthermore, I understand that in the unlikely event that any supervisor, counselor, or counselor-in-training knows me from another non-therapy setting, he/she will immediately leave the consultation session and will not observe, seek, or be given any information regarding myself or my treatment.  I understand that I may withdraw this consent to record video at any time (in writing).  I have had an opportunity to ask questions and have had my questions answered satisfactorily.

Client Signature: ____________________________________________________________	Date: ______________________________

Counselor Signature: _________________________________________________________	Date: ______________________________

Keep this page for your records.

OFFICE POLICIES

Please read the following information carefully, as it contains important information about our practice and policies.  Note any questions or concerns you have, and we can discuss them before beginning counseling.  After you initial each paragraph and sign this document, it will constitute a binding agreement between us.

Payment and Fees:  You are expected to pay the standard fee of $100 per 50 minute session at each session, unless other arrangements have been made.  If longer sessions occur, the additional fee will be billed at the rate of $20 for each additional ten minutes (e.g., $120 for a 60 minute session, $140 for a 70 minute session, etc.).  Fees for additional time or services, including travel time, will be prorated at our regular fee.  Such additional services may include, but are not limited to, consultation with other professionals, preparation of reports or correspondence, and phone calls lasting over 10 minutes.  Any court appearances will be billed at $250 per hour, including preparation and travel time.  Acceptable forms of payment are cash, check, or money order.  If your account has insufficient funds to cover a check, you will be charged an additional $10 to cover bank fees and will be required to pay with cash for all sessions thereafter.  Please notify us if any problem arises during the course of counseling regarding your ability to make timely payments.  _____

Overdue Payment:  If your account is more than 30 days overdue and suitable arrangements have not been agreed to, we have the option of using legal means to secure payment, including collection agencies or small claims court.  (If such legal action is necessary, the costs of bringing that proceeding will be included in the claim.)  _____

Cancellation:  Since your appointments involve the reservation of time specifically for you, and as this is the basis of our livelihood, a minimum of 24 hours’ notice is required for rescheduling or canceling an appointment.  A $25 fee will be charged for the first session missed without such notice.  You will be charged the full fee for any further late cancellations.  Repeated cancellations (more than two) without sufficient notice may result in the termination of counseling.  _____

Insurance:  Although we do bill some insurance companies directly, it is your responsibility to verify the specifics of your coverage and to make arrangements for such billing during your intake session.  If we do not bill your insurance company directly, payment in full will be expected at the beginning of each session, and at your request we will provide you with a statement of services which you can then submit to your insurance company for reimbursement.  Please be aware that submitting an invoice for reimbursement carries a certain amount of risk, as we cannot control how your information is used once submitted and not all therapeutic issues are reimbursable.  _____

Phone Numbers:  If you need to contact us, please leave a message for us at 720-685-1700.  We will return your call as soon as possible during business hours.  Although we try to be prompt in responding to messages, due to having a very busy practice our goal is to return calls within 48 business hours (Monday through Friday, 8 a.m. to 5 p.m.).  We do not check calls outside of business hours, including weekends, holidays and during scheduled office closures (which will be noted in the voicemail greeting for the office as they occur).  _____

Emergencies:  Due to the nature of our work, we are often not immediately available by telephone.  We do, however, check voicemail periodically for messages (as above).  Therapeutic calls are prorated based on the regular hourly fee.  If you are facing a life threatening or other crisis situation and need to talk to someone immediately, call 911 or go to the nearest hospital emergency room.  _____

E-Mail, Texting, and Online Social Networking Policy:  Because it is not possible to guarantee the confidentiality of e-mail communications, please use discretion in deciding whether to communicate with us via e-mail.  We cannot be held responsible for any information lost in transit or viewed by a third party.  E-mail should only be used for brief, general questions.  Hence, emergencies, therapeutic issues, sensitive personal information, and cancellations should all be communicated to us over the telephone or in person.  We do not communicate with clients by text messages, and ask that you do not use this method of communication with us, either.  Likewise, we do not communicate with clients via online social networking sites (e.g., Facebook, Twitter, etc.).  _____  

Minor Children:  If the client is a minor child, both parents must sign all intake documentation before counseling sessions can begin.  If the parents of the minor child are legally separated or divorced and one parent has been assigned sole authority for decisions regarding mental health counseling for the minor child, the most recent executed court order regarding this authority must be provided and that parent must sign all intake documentation before counseling sessions can begin for the minor child. Parents of a client minor child are responsible for advising us immediately of any change in marital status and/or court orders regarding parental authority regarding mental health counseling for the minor child.  Parents of minor children under fifteen years of age must remain in the reception area during their child’s session.  _____ 

Litigation Limitation:  Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a sensitive and confidential nature, it is agreed that should you be involved in legal proceedings, neither you nor your attorney, nor anyone else acting on your behalf will call on us to testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested.  _____

Client Signature: _______________________________________________________________	Date: _________________________

Counselor Signature: ____________________________________________________________	Date: _________________________
Keep this page for your records.

Fill out this form if you would like us to be able to communicate with any other individuals.  As noted in our policies, if you are also being seen by a psychiatrist, it is our policy to require an authorization to exchange information regarding your medical and mental health treatment.  Bring this form with you to your first session, whether or not you completed the information.

AUTHORIZATION TO EXCHANGE INFORMATION

I (your name), ______________________________, hereby authorize Riverdale Counseling Center, Inc. to exchange written and verbal mental health treatment information and records obtained in the course of counseling treatment, to the following persons and /or parties (please include name, address and phone number):
	_________________________________________
	_________________________________________
	_________________________________________
	_________________________________________
	_________________________________________

I understand that I have a right to receive a copy of this authorization.  I understand that any cancellation or modification of this authorization must be in writing.  I understand that I have the right to revoke this authorization at any time unless Riverdale Counseling Center, Inc. has taken action in reliance upon it.  And, I also understand that such revocation must be in writing and received by Riverdale Counseling Center, Inc., 36 South 18th Avenue, D-3, Brighton, CO  80601 to be effective.

This disclosure/exchange of information and records is authorized for the following purpose(s):

_____	Notification of beginning and/or ending of treatment.
_____	Periodic summary of progress.
_____	Coordination of service/treatment planning.
_____	Educational information/records.
_____	Past treatment.
_____	Psychological/psychiatric evaluation.
_____	Financial information/payment arrangements.
_____	Other (specify): ______________________________

This consent for release of information is given freely, voluntarily and without coercion.  Any information I authorize other individuals to release to Riverdale Counseling Center, Inc. will be held strictly confidential and will not be released without my written permission except as permitted by State or Federal law.  This authorization is effective for one year from the date below, or as long as the case remains open, whichever is longer.

Client Signature: ______________________________	Date: ____________________

Counselor Signature: ___________________________	Date: ____________________