Glenn E. Boyd, Ph.D., LPC, LMFT

Glenn E. Boyd, Ph.D., LPC, LMFT 10701 Corporate Dr., Suite 220 Stafford, TX 77477 (832) 472-3566 (281) 494-4307 Fax [email protected]

Intake Information

Name: ______Address: ______

Phone numbers: Home______Work______Cell phone______Email address______

Date(s) of Birth: ______

Social Security Number (used only if necessary):______

Marital Status: ______

Employment: ______

Emergency contact (name and phone number): ______

Rights and Responsibilities: I have reviewed and signed both the HIPAA and the Informed Consent and have asked questions or requested copies of either/both: ______(initials)

I authorize Dr. Boyd to release information to: ______Signature: ______

I authorize Dr. Boyd to communicate with my doctor: Yes No Signature: ______Name of Doctor: ______Phone number of Doctor: ______

Dr. Boyd recommends that you contact your doctor regarding your appointment with him to discuss whether other conditions might also explain your current problems.

I affirm that I am not currently suicidal or homicidal, but that if I should determine that I am or might be, I will contact Dr. Boyd immediately. Signature: ______Intake Information, page 2

I/we give Dr. Boyd my permission to work with the minor child/children named below. I understand that confidentiality also extends to children and adolescents, but that pertinent information will be disclosed to a parent as Dr. Boyd sees fit if he believes it is in the best interest of the child.

Child or children’s name(s):______

Parent signature: ______

Insurance Information:

I give Dr. Boyd permission to copy my insurance card and to contact my insurance company (unless already contacted) to determine what if any benefits may help cover the cost of my therapy. I understand that I will be responsible for any deductibles, co-pays or co-insurances that apply. Signature: ______

Date: ______

Tentative Treatment Plan Recommendations:

I/we have discussed and understand the tentative treatment plan recommended by Dr. Boyd and also understand that it can and probably will be amended collaboratively as treatment progresses: Signature:______Date:______