Kurt M. Hadrika M.S.,L.M.F.T.,L.M.H.C. Personal Counseling Solutions, Inc./Orlando
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Intake Forms
Qualifications
Telehealth treatment consent
INTAKE FORM
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Name
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First
Last
Address
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City
State
Zip Code
Country
Date of Birth
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mm/dd/yyyy
Phone Number
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Email
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Marital Status
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Employment Status
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Years of Education
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Members of Household and Age
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Please list each member of your household and their age. If no other household members, state "none".
Emergency Contact Name
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First
Last
Emergency Contact Phone Number
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Insurance Information
Policy Holder Name
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First
Last
Policy holder name as it appears on Insurance Card. If no insurance, type "NA"
Policy Holder Date of Birth
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mm/dd/yyyy If no insurance, type "NA"
Policy Holder's Address
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Line 1
Line 2
City
State
Zip Code
Country
If no insurance, type "NA"
Policy Information
Insurance Company Name
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Please state full company name. If no insurance type "NA"
Insurance ID #
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Please list the ID number from your card, not the Group number. If no insurance type "NA"
Insurance Company Phone Number
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Phone number listed on the back of your insurance card
Clinical History
Have you had previous counseling?
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No
Yes
Have you ever taken any psychotropic medications?
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No
Yes
If you answered "Yes" please list which medications?
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Have you any current or historical intention to do harm to yourself?
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No
Yes
Have you any current or historical incidents of self-injurious acts?
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No
Yes
Do you have any history of disability?
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No
Yes
What are your goals for therapy?
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Client Symptom Checklist
Please answer the following questions
1. Do you feel sad, blue or empty, crying for no reason?
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Never
Seldom
Occasionally
Often
Always
2. Have you lost or gained significant weight recently?
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Never
Seldom
Occasionally
Often
Always
3. Do you have any sleep related issues?
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Never
Seldom
Occasionally
Often
Always
4. Do you feel fatigued or have loss of energy nearly every day?
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Never
Seldom
Occasionally
Often
Always
5. Do you feel a sense of guilt for things in the past?
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Never
Seldom
Occasionally
Often
Always
6. Do you feel that you don’t have anything to look forward to?
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Never
Seldom
Occasionally
Often
Always
7. Do you have difficulty concentrating or making decisions?
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Never
Seldom
Occasionally
Often
Always
8. Do you have angry outbursts that are difficult to control?
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Never
Seldom
Occasionally
Often
Always
9. Do you ever experience a racing heart, shortness of breath, feel shaky, or tremble for no apparent reason?
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Never
Seldom
Occasionally
Often
Always
10. In normal circumstances, do you ever experience intrusive or repetitive thoughts? These may include fears of contamination, or other self safety issues.
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Never
Seldom
Occasionally
Often
Always
11. Do you have any repetitive or perfectionistic rituals that others may consider excesive?
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Never
Seldom
Occasionally
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Always
12. Has anyone physically hurt or touched you in a manner that causes current distress?
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Never
Seldom
Occasionally
Often
Always
13. Do you have nightmares?
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Never
Seldom
Occasionally
Often
Always
14. Do you have any concerns with relationships at home?
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Never
Seldom
Occasionally
Often
Always
15. Do you have any concerns with relationships at work or school?
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Never
Seldom
Occasionally
Often
Always
16. Do you feel disconnected from your feelings?
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Never
Seldom
Occasionally
Often
Always
17. In the past month, have you or anyone else you know ever thought you should cut down on your drinking or drug use?
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Never
Seldom
Occasionally
Often
Always
18. Do you use alcohol or drugs even though you know that you will have negative social, physical or behavioral consequences?
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Never
Seldom
Occasionally
Often
Always
Please Read the Following:
HIPAA Acknowledgement:
Consent for Evaluation and Treatment
The services I provide can include individual therapy, relationship therapy, family therapy, Brief Solution Focused treatment, EMDR treatment, Conflict Management treatments or Cognitive Behavioral Therapy. The sessions will be conducted either in my office, or via a HIPAA compliant video conferencing platform. I will always provide you an explanation about the nature and purpose of the treatment, possible alternative treatment methods and/or procedures and you will be informed about any potential risk involved. My goal with you will be to always maximize your learning and solution focus. I will work with you to create a reasonable action plan, and you have the right to refuse any recommendations at any time. All reasonable efforts will be made to accomplish our mutually agreed upon goals however there is no guarantee that the desired results will be obtained.
Confidentiality
All information that is shared during our sessions is completely private, and I will not release any information to outside sources without your written consent. I do keep records of our progress and will be happy to review with you these records and explain/ answer any questions you may have. Revelation of abuse or neglect of children or elders, or if you are a danger to others or yourself are issues where your right of confidentiality can be waived. Workplace threats or community threats may also be an area where confidentiality will be impacted. In rare occurrences, a court of law can require records of your treatment, in which case I would have to comply.
Records
Your file is confidential and if requested in writing, information can be released to you or an entity you designate. In most cases if a third-party wants the file, I will write a brief report that will be a summary of your treatment only upon your written request. If you are having sessions with me as a couple, and at some point one or both of you request information be sent to a third party, you both will have to sign a release and agree to that action.
Cancellations
Please provide me 24 hours notice in the case where you will not be able to make our scheduled appointment. If you cancel for a non-emergency reason providing me less than 24 hours notice, there will be a charge of $50.00. If you do not show and not call, you will be charged per what I normally collect in total for each session. There may be emergency times when you need to call me that previous evening or there may be times where I need to adjust your session due to an emergency I may need to facilitate.
Financial policy
I will collect any co-insurance or deductible due at the beginning of each session. I accept check, credit card or cash. Checks are made out to: PCS LLC. I will encourage you to use insurance if you have it, and for those clients who do not have coverage are welcome to
pay out of pocket at the following rates:
Initial hour for individual or couples counseling: $150
Follow up sessions: $130
I've read and understood the above HIPAA statement that includes; Consent for Evaluation and Treatment, Confidentiality, Records, Financial Policies and Cancellations. I have read and understand the above information and I do consent to psychotherapy treatment. A copy of this HIPAA required form will be kept in your clinical chart, thus acknowledging that you are giving your consent and have reviewed my office policies and procedures.
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I agree
Please type your name here as an electronic signature of your understanding of this HIPAA agreement
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If you have any inquiries or questions, please do not hesitate to submit them in the box below.
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