Denise O’Doherty Client Intake Form Please fill out the information below completely prior to your first appointment. Client Information Name First Last Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Cell PhoneHome PhoneWork PhoneDate of Birth MM slash DD slash YYYY Marital Status Formal Education/ Major Occupation Where do you work? How Long? Present Position Do you travel with your job? Is your job a source of stress? Do you like your job? Where were you born? How long have you lived in Houston? Do you have any Religious or Spiritual Affiliation? Live With Relationship to this person How Long Together? Pets? Children (names, ages)Use the to add multiple childrenChildren NamesAge How many times married? Health IssuesSignificant Surgeries in the pastPrimary Doctor How long? Prescription Medications that you are taking presentlyUse the to add multiple medicationsMedication NameDosageFrequency Please list any anti-depressants, anxiety medications, mood stabilizers you have been on in the past and when.Use the to add multiple medicationsMedication NameDosageFrequencyCurrently Taking? Addictions: (drug, alcohol, food, love, sex, spending, gambling, cigarettes, other)How many days a week do you drink? How many drinks do you average each time? Any DWI’s? Ever in treatment for an addiction? If so, where and when?For how long? Have you ever attended a 12 Step meeting? (AA, Al-Anon, ACOA, Coda, etc.) When? For how long? If in recovery, how long? Previous Psychotherapy. With whom? When? For how long? Did you achieve the results you wanted? Do you have a pattern of putting other people’s needs and wants ahead of your own? With whom? Do you prefer to avoid conflict /confrontation at all cost? Do you have a problem with managing anger, road rage or bullying? What do you do for exercise? How often? Do you do any volunteer work? Do you belong to any Civic, Social or Professional Organizations? Any in the Past? Have you ever attended any type of Personal Development Workshop of any Kind? When? (ie: Landmark Education, More To Life, IMAGO couples or singles workshop, Marriage Encounter, Inner Child, The Mankind Project, The Woman Within, etc) Do you consider yourself to have a good support system? Who is in your support system? Do you have any strong religious or spiritual affiliation? If confidence is doing something well, and self-esteem is how you feel about yourself on a 1-10 with 10 being the highest, how do you rate your confidence? If confidence is doing something well, and self-esteem is how you feel about yourself on a 1-10 with 10 being the highest, how do you rate your Self-Esteem? Are you an introvert or an extrovert? Reason for visitWhat results would you like to achieve in therapy?Referred By: Would you like to be added to my mailing list and receive occasional information on relationships, personal growth and health? Yes General Office PolicyMy acknowledgment of each of the items below and via my submission of this form, I designate that I fully understand the office policies regarding insurance, fees, cancellations, emergencies, insurance and using zoom and the internet. Insurance* Insurance Acknowledgment Almost everyone I see gets reimbursed through their insurance using Out-of-Network benefits. You may want to check with your insurance company to see if you have Out-of-Network benefits prior to therapy. You may also want to find out your deductible, what percent of each session is covered and if there is a limit to the number of sessions allowed. I can give you a receipt for your visits which will include all the necessary information needed by the insurance company. Receipts are given quarterly, at the end of therapy, at the end of the year or when you do your taxes. You can request a time that works for you. Once you have a receipt from me, you can send it to your insurance company for reimbursement. The address of where to send it, is usually on the back of your insurance card. Fees / Session Length* Fees / Session Length Acknowledgment The fee for each session is required at the time of service. Hourly sessions last approximately fifty (50) minutes. An hour and a half session would last 75 continual minutes. Credit cards are best. Venmo and Zelle are other options. Individual (50 min.) - $190 Reports or Letters - $95 per 30 min. Family/ Couple (50 min.) - $190 Returned Checks - $25 per check Group (90 min.) - $ 75 Missed Appointments - service rate Consultation (50 min.) - $190 Court/Attorney Consultation - $250 per hourCancellations* Cancellations Acknowledgment For all scheduled appointments, 24 hour notice is required or you will be charged the full hourly fee. For any first time appointment where a 24 hour cancellation notice is not made or if the client does not show, there is a $95 charge for missing the reserved 50 minute appointment time. Emergency Policy* Emergency Policy Acknowledgment My practice is by appointment only as opposed to crisis intervention. If you are in a crisis and want to talk to me, please call me and leave a message. I check my voice mail and messages several times a day and can be reached by calling (713) 823-4001. In case of an emergency and you can not reach me, you can call 911, United Way Crisis Hotline (713) 228-1505, MHMRA Crisis Unit (713) 970-7000 or go to the nearest hospital emergency room.Notice of Privacy Act* Notice of Privacy Act Accepted Notice of Privacy Act Denied Please confirm that you have been offered a copy of the Notice of Privacy Act. Confidentiality* Confidentiality Acknoledgement Zoom and other forms of media are not encrypted. By initialing, you are saying you give permission to have sessions via this media and that you give permission and are comfortable receiving information from me, including but not limited to handouts, articles and therapy receipts via internet. Consent for Professional ServicesClient Rights 1. You have the right to know my qualifications. I am licensed by the state of Texas as a Licensed Professional Counselor and as a Licensed Marriage and Family Therapist. I am a certified IMAGO Relationship Therapist. I have a masters degree in Psychiatric Nursing. I have been in private practice since 1982. 2. You have the right to choose your mental health provider. 3. You have a right to decide how long you stay in treatment. 4. You have a right to information about your treatment. 5. You have a right to treatment with respect and dignity. Limits of Confidentiality You have a right to confidentiality with certain legal and ethical exceptions: A. If you threaten harm or death to another person or to yourself, physically or with a communicable disease, I am required by law to inform the appropriate authorities. B. If a court of law issues a legitimate subpoena, I am required by law to provide the information specifically described in the subpoena. C. If you reveal information suggesting child and /or elder abuse and neglect, I am required by law to report this to the appropriate authorities. D. If a minor reveals information suggesting abuse, I am required to notify appropriate authorities. E. If you are in therapy or being tested by order of a court of law, the results of treatment or tests ordered must be revealed to the court. F. If I need to obtain consultation on your case. (In this instance, I will keep it as confidential as possible by using generic names, such as John and Mary.) G. If your mental health is called into question. H. If you authorize me and / or my agents to file a claim and bill a third party medical or necessary information to process these insurance claims. Informed Consent* Informed Consent Acknowledgment Having read the above, I am requesting services and give my informed consent to psychotherapeutic treatment with Denise O'Doherty LPC, MSN.