Tina D. Weldy, LMHC, Mental Health Counseling

600 S. Main St., Suite 310 Tina D. Weldy, LMHC, Mental Health Counseling Elkhart, IN 46516 Ph: (574) 536-7580 Fax: (574) 538-2383 [email protected]

Adult Client Information

Name______Date______

Birthdate ______/_____/______Soc. Sec. No.______/______/______

Address:______

City ______State _____ Zip Code ______

Preferred Phone ______Ok to text? Y__N__ Ok to leave discreet message? Y__N__

Alternate Phone ______Ok to text? Y__N__ Ok to leave discreet message? Y__N__

Email ______Ok to email you? Y__N__

*Note that emails may not be confidential.

How did you find out about our office? ______

Emergency Contact

By listing below, you give your consent to contact this person in case of a life-threatening emergency.

Emergency Contact Name ______

Relationship to You ______

Address: ______

Telephone: ______

Insurance Note: If you bring your insurance card, you do not need to complete this section.

Insurance Company______

Policy Holder Name______

Policy Holder Employer ______

Policy Holder Soc. Sec. No. ______/______/______Birthdate______/______/______

Policy Holder Address (if different than client’s)______

of 8 ______

Policy Number ______Group Name/No. ______

Secondary Insurance Company Information ______

______

Tina D. Weldy, LMHC, Mental Health Counseling

Informed Consent. Thank you for choosing Tina D. Weldy, Mental Health Counseling, for your mental health services. Tina Weldy is a Licensed Mental Health Counselor (LMHC), licensed by the state of Indiana to provide therapy services. She provides counseling services to adolescents, adults and families using an eclectic approach which utilizes cognitive behavioral therapy, insight-oriented, brief therapy, and strength-based therapy, as well as other therapy approaches appropriate to individual situations.

Confidentiality. Your verbal communication and clinical records are strictly confidential except for: a) information shared with a consulting psychologist for the purposes of reimbursement; b) information shared with your insurance company to process your claims; c) information shared about physical or sexual abuse of a child or vulnerable elder (by Indiana State Law we are obligated to report this to the Office of Family and Children); d) where you sign consent to release information to a specific person or organization; e) if you provide information that indicates that you are in danger of harming yourself or someone else; f) information necessary for case supervision or consultation, or g) when court ordered to disclose information by a judge.

Please also note that on-line communications are not HIPAA-compliant and are best restricted to communication about appointment dates and times, changes in appointments, and so on. This applies to e-mail and text messages.

Emergency Situations. In an emergency situation for which a client or guardian feels immediate attention is necessary, please call 911 or go to your nearest emergency room. You may call this office for follow-up support as well.

Financial/Insurance Issues. As a courtesy, your insurance company, HMO, or third party payor will be billed for you. Please plan to pay your copay or other non-insurance-covered fees at time of service. By signing below, you authorize payment of medical benefits to be made directly to Tina D. Weldy, Mental Health Counseling. You also authorize the release of any medical or other information necessary to process claims for services provided now and in the future, recognizing your responsibility for nonpaid services. Note that unpaid services may be turned over for Collections. All additional fees owed will be charged to the client.

Notice of Privacy Practices and Client Rights. A copy of our Notice of HIPAA Privacy Practices and Client Rights document will be provided upon request.

Authorization

Consent to Communicate with Primary Care Provider (PCP). Some insurers request that we communicate with your primary doctor in order to better coordinate care.

of 8 □ Yes, you may communicate with my doctor: ______by oral or written communication, regarding diagnosis, treatment, symptoms, prognosis, medications prescribed, and dates of treatment. □ No, please do not contact my primary care doctor.

Permission to Treat

By signing, I authorize Tina D. Weldy, LMHC to offer treatment to me.

______/_____/______

Signature of Client Date

Printed Name ______

of 8 Tina D. Weldy, LMHC, Mental Health Counseling

ADULT INTAKE INFORMATION

Name______Date______/______/______

Please answer the following questions to the best of your ability. You may skip questions that are not relevant or that you are uncomfortable answering. Explanation of Problem

Please state your main reason for making this appointment.

______

Approximately how long have you been dealing with this issue? ______

Do you have thoughts of harming yourself? Y___N____

If yes, please answer the following questions:

Are you feeling suicidal today? Y___N____

Have you ever attempted suicide? Y___N____

If yes, how long ago was the most recent attempt? ______

Total number of suicidal attempts: ______

How likely are you to harm yourself in the next 24 hours?

___Almost certainly ___Probably Not ___ Definitely Not

What keeps you from harming yourself? ______Alcohol and drug use: Has use of alcohol or drugs caused problems for you? Y____ N_____

If yes: Alcohol____ Drugs______

Type of problems: Legal ___ Family ___ Job ___ Other ______

Current problems: Y___N____ Past problems: Y___N____ If in the past, how long has it

been since you quit using? ______

Do you have/have you had an eating disorder? Y___N____

□ Bulimia □ Anorexia □ Compulsive overeating □ None Other:______

Do you have any problems with sleep?

□ Sleep too much □ Sleep too little □ Poor quality □ Disturbing dreams □Difficulty falling asleep Other: ______

Have you ever been a victim of abuse? Y___N____

of 8 □ Emotional □ Verbal □ Physical □ Sexual

If yes, relationship of abuser to you: ______

Have you ever abused someone else? Y___N____ Relationship ______

of 8 Legal Information

Are you currently involved in any court proceedings? Y___N____

Were you court-ordered to participate in therapy? Y___N____

Are you on probation? Y___N____ Name of Probation Officer: ______

Explanation of legal issue: ______

of 8 Demographic Information

Marital Status: □ Single □ Married □ Significant Other □ Divorced □ Separated

Names and ages of children: ______

How would you describe your relationship with your significant other/spouse?

□ Excellent □ Very Good □ Average □ Problematic

How would you describe your relationship with your family of origin (parents, siblings, or other family

members)? □ Excellent □ Very Good □ Average □ Problematic

Do you have religious and/or spiritual beliefs that are important to you? If so, briefly describe: ______

Sexual Orientation: □ Heterosexual □ Gay or Lesbian □ Bisexual Other ______

Gender: □ Female □ Male □ Transgender Other ______

Military: □ Active □ Veteran □ Reserves □ National Guard □ Retired

Employment: □ Employed □ Underemployed □ Unemployed □ Student □ Homemaker □ Retired

Other ______

Employer: ______School:______Job Title: ______Job Satisfaction Rating: □ Very high □ High □ Average □ Low □ Very Low

Medical Information

Current medical problems: ______

Are you taking any medications? If so, please list them: ______

Psychiatrist (if applicable): ______

Have you seen a therapist in the past? Y___N____ Name of previous therapist______

Have you ever been hospitalized for mental health problems? Yes___ No____

If yes, where were you hospitalized? ______

Dates of hospitalization: ______

of 8 If you would like to include any further information, you may use the space below or attach additional information: ______

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