Loading...

Centennial Consulting and Associates, LLC
Charles G. Allen, Ph.D.
Licensed Psychologist #1372

 

Today's Date: March 29, 2024

Centennial Consulting and Associates, LLC is a Colorado Limited Liability Company (LLC) which operates a consulting firm, offering individual, group, and family psychotherapy or consultation.

TREATMENT AUTHORIZATION

I hereby authorize Centennial Consulting and Associates, LLC to administer such care as is necessary, in their judgment (including diagnostic procedures, consultation and/or psychotherapy) for clients listed herein.

DISCLOSURE of ASSOCIATES

Dr. Charles G. Allen is a Licensed Psychologist (#1372) in the State of Colorado.  Dr. Allen received his Bachelor's degree in 1974 from the University of Nebraska-Lincoln, his Master's degree in 1977 from Chapman College and his Ph.D. in 1988 from the University of Denver, all in Psychology. During the process of training, Dr. Allen completed his one-year full-time clinical internship at the V.A. Medical Center in Topeka, KS. He completed two years of post-doctoral clinical supervision as was required for licensure. Dr. Allen began his career in the mental health field in 1972 as a Para-Professional for the Crisis Hotline at the University of Nebraska's, Mental Health Center.  Dr. Allen uses a Cognitive-Behavioral Therapy (CBT) approach to treatment. This approach to therapy teaches a person that thinking controls one's behavior and emotions.

The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The Board of Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. Under the law, a client has the right to receive information about the methods of therapy and expected duration of treatment for their condition.

As to the regulatory requirements applicable to mental health professionals: A Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a masters' degree in their profession and have two years of post-masters' supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a masters' degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAC I) must be a high school graduate and complete required training hours and 1000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor's degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements. A Registered Psychotherapist is registered with the State Board of Registered Psychotherapists, is not licensed or certified, and no degree, training or experience is required.

 

AGREEMENT

IT IS UNDERSTOOD AND AGREED that this Agreement and the following Hold Harmless, Covenant Not to Sue and Release are part of the consideration from the Client to the Corporation, jointly and severally, for the privilege of receiving services, visiting, observing or touring the facilities of the LLC. The Client hereby agrees and assumes any and all risks of injury or damage from them or by them, and releases LLC from any claim that its employees or agents are or may be negligent in connection with Client's participation in LLC's programs. Client expressly agrees that this Client Agreement, Hold Harmless Clause, Covenant Not to Sue and Release is governed by the laws of the State of Colorado and is intended to be as broad and inclusive as is permitted by Colorado law and that in the event any portion of the Agreement is determined to be invalid, illegal or unenforceable, the validity, legality and enforceability of the balance of the Agreement shall not be affected or impaired in any way and shall continue in full legal force and effect. Client voluntarily assumes all risk of injury from the failure of treatment including but not limited to death by suicide. CLIENT ACKNOWLEDGES THAT THIS IS A CONTRACT AND AGREES THAT IF A LAWSUIT IS FILED AGAINST THE LLC, ITS OWNERS, EMPLOYEES OR AGENTS, FOR ANY INJURY OR DAMAGES IN BREACH OF THIS CONTRACT, THE UNDERSIGNED WILL PAY ALL ATTORNEY'S FEES AND COSTS INCURRED BY THE CORPORATION IN DEFENDING SUCH ACTION.

IN CONSIDERATION of Centennial Consulting & Associates, LLC agreeing to undertake this case I (Client) agree to the following:

1. To keep all scheduled appointments and shall give at least one (1) hour notice of intention to cancel any appointment and will pay the full fee for any appointment that is missed without notice. To assume full responsibility for payment of all charges for professional services rendered.  Agreed upon payment is due in full after each session unless special arrangements are made in advance. Client agrees to pay a fee of $35.00 for any returned check(s). In the event that my account is not paid-in-full within 90 days after therapy or consultation has terminated, simple interest will be charged on the unpaid balance at an annual percentage rate of 21%. I understand that if I fail to pay all charges for professional services rendered to the client by Centennial Consulting and Associates, LLC, my account will be referred to their attorney for collection. I will be notified in advance that my name is about to be released and an opportunity to settle. I will be given the name of that attorney and legal action will be initiated which will seek payment of all costs, charges, and expenses for professional services plus interest on the unpaid balance, attorneys' fees, and court costs. If such action is necessary, I understand and hereby agree that my name and necessary (PHI) information related to my location and account balance may be released. I understand that information related to the content or nature of the therapy will not be released unless it is necessary for collection.

2. I understand that Centennial Consulting and Associates, LLC will upon request provide the client (or responsible party) with a bill containing the required information for insurance reimbursement. Centennial Consulting and Associates, LLC is not a member of any insurance panel, thus the client or legal guardian must submit all documents and conduct all communication with an insurance company. For your own protection and privacy, Centennial Consulting and Associates, LLC will not submit any psychotherapy or billing information directly to an insurance company or an insurance sub-contractor without a signed Release of Information.

3. I understand that a psychotherapy relationship is considered privileged, which means, anything that is disucssed in therapy will be kept in strictest confidence within the confines of the law.  In order for a person to achieve maximum benifit from therapy, it is essential that unequivocal trust be established.  This will allow you to share the most private thoughts and memories of the issues that bring you into treatment.  Without this trust, your treatment is likely to fail.  Furthermore, I understand that the details of the most private issuse will not be documented.  I understand the potential risks of noncompliance with recommended treatment.  No guarantee or assurance has been given as to the duration or results that may be obtained from the psychotherapeutic process.

4. I understand that the law requires in the case of any reported or suspected child or elder abuse, these facts must be reported, in a timely manner, to the local Authorities and Protective Services. I understand that in the case where there is threatened physical harm toward myself or any other person(s), Centennial Consulting and Associates, LLC will make timely and reasonable efforts to notify the potential victim(s) and Authorities of such a threat.

5. I understand and agree that during couples or family therapy information may be discussed with other family members by Centennial Consulting and Associates, LLC, as long as they are directly involved in treatment. Written permission will be obtained for any communication with family members that are not directly involved in treatment. Centennial Consulting and Associates, LLC reserves the sole right to determine what information will be released to the parent or guardian when therapy involves a minor; the purpose of which is to maintain the best possible therapeutic relationship. Centennial Consulting and Associates, LLC will not withhold any information that may be harmful to the minor.

6. I consent to the use of telemedicine.  If applicable, I consent to the use of telemedicine for all minors listed herein.

7. I understand that a client has the right to obtain a second opinion from another therapist and/or terminate therapy at any time. Centennial Consulting and Associates, LLC will help the Client obtain a second opinion upon request or help find another therapist if necessary.

8. I understand that in a professional relationship, sexual intimacy is never appropriate and should be reported to the Board of Psychology Examiners listed above.

HOLD HARMLESS CLAUSE

I hereby promise and agree and understand that upon entering this course of Psychotherapy or Consultation under the express condition that Centennial Consulting & Associates, LLC, is free from any and all liability and claims for damage by reason of ANY INJURY to any person(s), including Client, or property of any kind whatsoever, and to whomsoever belonging, including Client, from any cause or causes whatsoever while engaged in the course of treatment, event or visiting the facilities, offered by the LLC either on its own premises or at any other place. The Client hereby promises and agrees, as part of the compensation to be paid the LLC for allowing the Client to receive a course of treatment, to indemnify and save harmless the LLC from all liability, loss, costs, and obligation of any and every kind on account of, or arising out of, any such injuries or losses, however occurring, during the period that the Client is engaged treatment.

COVENANT NOT TO SUE

The Client (or responsible party) hereby promises and agrees neither Client nor Client's heirs, successors, spouse, children, estates, personal representatives, or any other person or entity, will ever institute any action or suit at law or in equity against the LLC, nor institute, prosecute, or in any way aid in the institution or prosecution of any claim, demand, action or cause of action for damages, costs, loss of services, expenses or compensation for or on account of any damage, loss or injury either to person or property, or both, resulting or to result, past, present or future arising out of engaging in treatment and/or using the facilities.

RELEASE

In addition to the foregoing Agreement, Hold Harmless Clause, and Covenant Not to Sue, I hereby RELEASE and forever discharge the LLC, its successors, associates and assignees, from each and every right and claim which I now have, or may hereafter have, on account of any injuries, damages, to person or property, or illness that I may sustain as a result of engaging in treatment or consultation, whether or not arising from the negligent acts or omission of LLC or its associates, employees, officers, directors, independent contractors, or volunteers. I specifically release and forever discharge the LLC, its associates, successors, and assigns on account of any injuries, damages to person or property, or illness that I may sustain as the result of any negligent acts, omissions or non-compliance with treatment recommendation on my part. IT IS MY INTENTION by signing this paper to ban me forever from suing and to release the LLC, even as to injuries, damages, to person or property, and illnesses, rights and claims not mentioned here or not known to me.

I hereby certify that I have read and understood this document in its entirety and that all information submitted herein is true and accurate. I understand my rights as a client or as the client's responsible party. Furthermore, I understand the terms of this Treatment Authorization, Disclosure, and Agreement and upon request will be provided an electronic copy of this document. I read and understand the Notice of Privacy Practices (HIPAA). The staff of the LLC will upon request verbally review this document and I will ask to have any questions fully explained to me.

I DO HEREBY ATTEST THAT I AM 18 YEARS OF AGE OR OLDER AND EVERYTHING SUBMITTED HEREIN IS TRUE AND ACCURATE.  I DO HEREBY ATTEST THAT I AM THE PARENT OR LEGAL GUARDIAN OF ALL MINORS SUBMITTED HEREIN.  I UNDERSTAND THAT THIS DOCUMENT IS AN AGREEMENT, HOLD HARMLESS CLAUSE, COVENANT NOT TO SUE, RELEASE AND INDEMNITY FOR ALL CLAIMS FOR MYSELF AND ALL MINORS. I UNDERSTAND THAT BY SIGNING THIS AGREEMENT, I AM GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES IN CASE OF INJURY, DEATH OR PROPERTY DAMAGE FOR MYSELF AND ALL MINORS. I SPECIFICALLY AND KNOWINGLY AGREE THAT I EXPRESSLY AND IRREVOCABLY INTEND TO RELEASE THE LLC, ITS DIRECTORS, OFFICERS, EMPLOYEES, AND AGENTS FROM THEIR OWN NEGLIGENCE.

I Agree
to the terms and conditions of this TREATMENT AUTHORIZATION, DISCLOSURE and AGREEMENT.

Date signed: March 29, 2024

 

First Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
First Client(s) Date of Birth*
First Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
First Client(s) Signature*
Second Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Second Client(s) Date of Birth*
Second Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Third Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Third Client(s) Date of Birth*
Third Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Fourth Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Client(s) Date of Birth*
Fourth Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Fifth Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Client(s) Date of Birth*
Fifth Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Sixth Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Client(s) Date of Birth*
Sixth Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Seventh Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Client(s) Date of Birth*
Seventh Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Eighth Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Client(s) Date of Birth*
Eighth Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Ninth Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Client(s) Date of Birth*
Ninth Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Tenth Client(s) Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Client(s) Date of Birth*
Tenth Client(s) Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Client(s) Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Client's Family History

Spouse or Significant Other (Name/Age)

Children (Names/Ages)

Parents & Siblings (Name, Age, Relationship [great, fair, estranged]

Please provide address of MINORS listed herein that are not at the same physical address. (skip if they are all live at the same address).
Veteran Status
Please Check all that apply
Non-Veteran
Disabled (Service Connected) Veteran
Retired Military
Medically Retired from Military
I have never applied for a Disability
I have never sought treatment with the Department of Veteran Affairs.
I was referred by the Department of Veteran Affairs.
I am a veteran and understand I may be eligible for treatment at the Department of Veterans Affairs but choose not to seek treatment there.

Additional information regarding Veteran Status.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information & History
Employment *
Full-Time
Part-Time
Unemployed
Retired
Other

Employer/Occupation (current or former)
EDUCATION:
Student (H.S., College, Grad., etc)
High School (GED) Graduate
Some College
College Graduate
Graduate (Professional) Degree
Other

Schools Attended (H.S., College, Grad/Professional)
Current Psychological Issues (check all that apply) *
Recent weight Gain or Loss
Trouble falling or staying asleep
I feel rested/refreshed when I awaken
I frequently experience nightmares
I have lost interest in my normal activities
I feel depressed or fatigued recently
I am currently having suicidal thoughts
In the past I have had thoughts (or acts) of hurting someone else
I have thought about/attempted suicide in the past
I am currently thinking of hurting someone else
I have symptoms of PTSD
I have symptoms of Anxiety/Panic
I have problems with Anger or Anger Management
I have experienced abuse (physical, sexual, verbal) or neglect

How long have you had the symptoms listed above? *

Please describe briefly the reason for seeking consultation: *

Treatment Goals (What would you like to accomplish?)
Major Medical Problem*
None at this time
Yes (see below)
Prior problems resolved (see below)

Brief description of your medical problems.

Primary Care Physician and Phone #
Prior Psychological or Substance misuse/abuse Counseling*
No
Yes
Past counseling somewhat helpful
Past counseling did not help
Current Legal Problems*
No
Yes (see below)

Briefly, describe current or past Legal problems.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!