Denise O’Doherty

Licensed Professional Counselor, Licensed Marriage and Family Therapist, Drug and Alcohol Counselor, Registered Nurse

New Client Intake Form

Client Information

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  • Use the to add multiple children
    Children NamesAge 
  • Use the to add multiple medications
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  • Use the to add multiple medications
    Medication NameDosageFrequencyCurrently Taking? 

  • General Office Policy

    My 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.
    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.
    The fee for each session is agreed to in advance, and 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 card payment is preferred.
    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.
    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.
    Please confirm that you have been offered a copy of the Notice of Privacy Act.
    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 Services

  • Client Rights
    1. 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. 2. You have the right to choose your mental health provider.
    3. 3. You have a right to decide how long you stay in treatment.
    4. 4. You have a right to information about your treatment.
    5. 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:

    1. 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.
    2. B. If a court of law issues a legitimate subpoena, I am required by law to provide the information specifically described in the subpoena.
    3. 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.
    4. D. If a minor reveals information suggesting abuse, I am required to notify appropriate authorities.
    5. 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.
    6. 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.)
    7. G. If your mental health is called into question.
    8. 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.
    Having read the above, I am requesting services and give my informed consent to psychotherapeutic treatment with Denise O'Doherty LPC, MSN.