Kurt M. Hadrika M.S.,L.M.F.T.,L.M.H.C. Personal Counseling Solutions, Inc./Orlando
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    INTAKE FORM

    mm/dd/yyyy
    Please list each member of your household and their age. If no other household members, state "none".

    Insurance Information

    Policy holder name as it appears on Insurance Card. If no insurance, type "NA"
    mm/dd/yyyy If no insurance, type "NA"
    If no insurance, type "NA"

    Policy Information

    Please state full company name. If no insurance type "NA"
    Please list the ID number from your card, not the Group number. If no insurance type "NA"
    Phone number listed on the back of your insurance card

    Clinical History

    Client Symptom Checklist

    Please answer the following questions
    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 INC. I will encourage you to use insurance if you have it, and for those clients who do not are welcome to 
    pay out of pocket at the following rates:

    Initial hour for individual or couples counseling:  $150
    Follow up sessions:   $130
    ​


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