Intake Form

Confidential

Name

Date picker

Client Birth Date

Sex:

Male

Female

Home Phone:

Cell Phone:

How did you find me?

Supplemental Assessment Questions:

Safety Assessment

Please check one or more of the following:

Sometimes I think about harming myself or suicide

Sometimes I think about harming others or homicide

I have physically harmed my body before

Sometimes I feel as though life is not worth living

I do not have thoughts of harming myself or others

Are you currently receiving psychiatric services or psychotherapy elsewhere?

Yes

Have you had previous psychotherapy?

Yes

If Yes, provider’s name

Have you had previous psychiatric services or psychotherapy?

Yes

If Yes, previous provider’s name

Are you currently in a romantic relationship?

Yes

If yes, how long have you been in this relationship?

On a scale of 1-10, how would you rate the quality of your current relationship?

Relationship Status:

Have you ever experienced a traumatic event?

Yes

When was your last physical exam?

Any significant physical health problems (sleep issues, chronic pain, disabilities)?

In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911.

Informed Consent: Therapy Process & Expectations

Partnership: We work together to reach your goals. I provide recommendations and welcome feedback, but you have the right to agree or disagree with any treatment plan.

Outcomes: Because every person is unique, I cannot guarantee specific results or an exact timeline for therapy. You will get the benefit

Consultation: To provide the best support, I sometimes consult with other professionals. Like me, they are bound by strict HIPAA privacy and confidentiality standards.

Ending therapy: While you may stop therapy at any time, please let me know your intention so that we can have a goodbye session and ensure a smooth transition.

Telehealth & Privacy

Video sessions: While I use secure platforms, 100% security cannot be guaranteed. If our connection fails, I will call you immediately to continue with a different platform.

Recordings: Neither of us may record sessions without the other's written permission.

Social media: To maintain professional boundaries, I do not accept "friend" requests or follow patients on social media.

Public privacy: If we run into each other in public, I will not greet you first to protect your confidentiality. You are welcome to say hello to me first if you wish.

Financial & Cancellation Policies

Insurance: Providing insurance info consents to the release of data needed for processing. While I submit claims as a courtesy, you are ultimately responsible for all costs, including deductibles and copays. If insurance hasn't paid within two months, the balance becomes your responsibility out-of-pocket.

Cancellations: Please provide at least 48 hours' notice to cancel or reschedule. Late cancellations or missed sessions will be billed to you, except in genuine emergencies.

By signing below, you acknowledge that you have read and understood these policies.

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Date picker

Printed Name

Intake Form

Supplemental Assessment Questions:

In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911.

4585 Hilton Pkwy Suite 202
Colorado Springs, CO 80907

Phone: (571) 477-1551
Fax: (719) 434-9914

FreedomCounseling@proton.me

Intake Form

Supplemental Assessment Questions:

In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911.

4585 Hilton Pkwy Suite 202 Colorado Springs, CO 80907

Phone: (571) 477-1551 Fax: (719) 434-9914

FreedomCounseling@proton.me

4585 Hilton Pkwy Suite 202
Colorado Springs, CO 80907

Phone: (571) 477-1551
Fax: (719) 434-9914