<p> 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]</p><p>Adult Client Information</p><p>Name______Date______</p><p>Birthdate ______/_____/______Soc. Sec. No.______/______/______</p><p>Address:______</p><p>City ______State _____ Zip Code ______</p><p>Preferred Phone ______Ok to text? Y__N__ Ok to leave discreet message? Y__N__</p><p>Alternate Phone ______Ok to text? Y__N__ Ok to leave discreet message? Y__N__</p><p>Email ______Ok to email you? Y__N__</p><p>*Note that emails may not be confidential. </p><p>How did you find out about our office? ______</p><p>Emergency Contact</p><p>By listing below, you give your consent to contact this person in case of a life-threatening emergency. </p><p>Emergency Contact Name ______</p><p>Relationship to You ______</p><p>Address: ______</p><p>Telephone: ______</p><p>Insurance Note: If you bring your insurance card, you do not need to complete this section. </p><p>Insurance Company______</p><p>Policy Holder Name______</p><p>Policy Holder Employer ______</p><p>Policy Holder Soc. Sec. No. ______/______/______Birthdate______/______/______</p><p>Policy Holder Address (if different than client’s)______</p><p>Page 1 of 8 ______</p><p>Policy Number ______Group Name/No. ______</p><p>Secondary Insurance Company Information ______</p><p>______</p><p>Tina D. Weldy, LMHC, Mental Health Counseling </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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.</p><p>Authorization</p><p>Consent to Communicate with Primary Care Provider (PCP). Some insurers request that we communicate with your primary doctor in order to better coordinate care. </p><p>Page 2 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. </p><p>Permission to Treat</p><p>By signing, I authorize Tina D. Weldy, LMHC to offer treatment to me. </p><p>______/_____/______</p><p>Signature of Client Date </p><p>Printed Name ______</p><p>Page 3 of 8 Tina D. Weldy, LMHC, Mental Health Counseling </p><p>ADULT INTAKE INFORMATION</p><p>Name______Date______/______/______</p><p>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</p><p>Please state your main reason for making this appointment.</p><p>______</p><p>______</p><p>Approximately how long have you been dealing with this issue? ______</p><p>Do you have thoughts of harming yourself? Y___N____ </p><p>If yes, please answer the following questions:</p><p>Are you feeling suicidal today? Y___N____</p><p>Have you ever attempted suicide? Y___N____ </p><p>If yes, how long ago was the most recent attempt? ______</p><p>Total number of suicidal attempts: ______</p><p>How likely are you to harm yourself in the next 24 hours? </p><p>___Almost certainly ___Probably Not ___ Definitely Not </p><p>What keeps you from harming yourself? ______Alcohol and drug use: Has use of alcohol or drugs caused problems for you? Y____ N_____</p><p>If yes: Alcohol____ Drugs______</p><p>Type of problems: Legal ___ Family ___ Job ___ Other ______</p><p>Current problems: Y___N____ Past problems: Y___N____ If in the past, how long has it </p><p> been since you quit using? ______</p><p>Do you have/have you had an eating disorder? Y___N____</p><p>□ Bulimia □ Anorexia □ Compulsive overeating □ None Other:______</p><p>Do you have any problems with sleep?</p><p>□ Sleep too much □ Sleep too little □ Poor quality □ Disturbing dreams □Difficulty falling asleep Other: ______</p><p>Have you ever been a victim of abuse? Y___N____ </p><p>Page 4 of 8 □ Emotional □ Verbal □ Physical □ Sexual </p><p>If yes, relationship of abuser to you: ______</p><p>Have you ever abused someone else? Y___N____ Relationship ______</p><p>Page 5 of 8 Legal Information</p><p>Are you currently involved in any court proceedings? Y___N____ </p><p>Were you court-ordered to participate in therapy? Y___N____ </p><p>Are you on probation? Y___N____ Name of Probation Officer: ______</p><p>Explanation of legal issue: ______</p><p>Page 6 of 8 Demographic Information</p><p>Marital Status: □ Single □ Married □ Significant Other □ Divorced □ Separated</p><p>Names and ages of children: ______</p><p>How would you describe your relationship with your significant other/spouse? </p><p>□ Excellent □ Very Good □ Average □ Problematic </p><p>How would you describe your relationship with your family of origin (parents, siblings, or other family </p><p> members)? □ Excellent □ Very Good □ Average □ Problematic</p><p>Do you have religious and/or spiritual beliefs that are important to you? If so, briefly describe: ______</p><p>Sexual Orientation: □ Heterosexual □ Gay or Lesbian □ Bisexual Other ______</p><p>Gender: □ Female □ Male □ Transgender Other ______</p><p>Military: □ Active □ Veteran □ Reserves □ National Guard □ Retired</p><p>Employment: □ Employed □ Underemployed □ Unemployed □ Student □ Homemaker □ Retired </p><p>Other ______</p><p>Employer: ______School:______Job Title: ______Job Satisfaction Rating: □ Very high □ High □ Average □ Low □ Very Low </p><p>Medical Information</p><p>Current medical problems: ______</p><p>Are you taking any medications? If so, please list them: ______</p><p>Psychiatrist (if applicable): ______</p><p>Have you seen a therapist in the past? Y___N____ Name of previous therapist______</p><p>Have you ever been hospitalized for mental health problems? Yes___ No____</p><p>If yes, where were you hospitalized? ______</p><p>Dates of hospitalization: ______</p><p>Page 7 of 8 If you would like to include any further information, you may use the space below or attach additional information: ______</p><p>______</p><p>Page 8 of 8</p>