General Client Intake Form Client Information (please print)

General Client Intake Form

Client Information (please print)

Client’s Name: ______________________________________________________ DOB (mm/dd/yy): _____________________

Sex (circle one): Male Female Intersex Gender: _____________ Race/Ethnicity:___________________________

Sexual Orientation: ______________________________________ Preferred Pronoun Usage: ________________________

Marital Status: ( ) Single ( ) Engaged ( ) Married ( ) Divorced ( ) Widowed ( ) Domestic Partnership

Who suggested you see a therapist? ( ) Self-Referral ( ) Friend ( ) Family ( ) Work ( ) Partner ( ) Other _____________

How did you hear about us? ( ) Psychology Today ( ) Google ( ) Insurance Company ( ) Other ________________________

Contact Information

Address: _________________________________________________________________________________________

Email: __________________________________________________________________________________________

Home Phone: ___________________________________ Mobile Phone: _____________________________________

Work Phone: _________________________________

Can we leave a message at home? ( ) Yes ( ) No At work? ( ) Yes ( ) No On cell? ( ) Yes ( ) No

Employer: ______________________________________________________________________________________

Address: _______________________________________________________________________________________

Emergency Contact

Name: ___________________________________________________ Relationship to you: _______________________

Address: ___________________________________________________________________________________________

Phone:: __________________________ Would you like to sign a release of information for this person? ( ) Yes ( ) No

Breaking Free Services Center for Wellness BreakingFreeServices.com | [email protected]

1501 S. Pinellas Ave., Suite P, Tarpon Springs, FL 34689 | 727-547-3692

Medical Information

Do you have any allergies? _________________________________________________________________________________

Do you take any medications? _______________________________________________________________________________

________________________________________________________________________________________________________

Primary Care Physician Name, Address, & Phone Number: _____________________________________________________

________________________________________________________________________________________________________

Do you want to share information with your PCP? ( ) Yes ( ) No

Payment/Insurance Information

Is the school board paying? ( ) Yes ( ) No

Primary Insured’s Name: ______________________________________________ Insurance Co.: ________________________

DOB (mm/dd/yy): ________________ SSN: ________________________________ Rel. to Client: ________________________

Employer: _____________________________________________________ Ins. Group #: ______________________________

Ins. Policy #: ___________________________________________________ Ins. Phone #: _______________________________

Additional Information

All appointments must be changed or cancelled 24 hours in advance to avoid a charge. Failure to give at least 24 hours notice

will be considered a “no show” and will be billed accordingly, i.e. the usual agreed upon fee.

I understand and agree that (regardless of my insurance status), I am ultimately responsible for the balance on my account for

any professional services rendered.

I certify this information is true and correct to the best of my knowledge. I will notify Breaking Free Services Center for

Wellness, LLC of any changes to this information.

Release of Information

In order to process my claim, I hereby authorize release of any medical or other information necessary for this purpose only. I

hereby assign all medical, including Major Medical benefits to which I am entitled, to the above named provider.

Print Client Name: _______________________________________________________________________

Client/Guardian Signature: ________________________________________________________ Date: _________________



Adolescent Intake Questionnaire

These questions are to be filled out only by the client & should be done so privately. These questions are designed

to help your therapist have a better understanding of what brings you to therapy & to start learning how to be

most helpful to you.

Name: ___________________________________________________________________ Age: _______________

Whose idea was it for you to come here?

( ) Mine

( ) My parents

( ) Other: __________________________

How do you feel about being here?

( ) It’s fine.

( ) I’m against this.

( ) I don’t care.

In your own words, why are you here? _____________________________________________________________

______________________________________________________________________________________________

School

What school do you go to? _______________________________________________________________________

What do you like about it?

________________________________________________________________________

What do you dislike about it? _____________________________________________________________________

Are you in any activities at school? What are they? ____________________________________________________

______________________________________________________________________________________________

What’s your best subject? Your worst? _____________________________________________________________

_____________________________________________________________________________________________

Breaking Free Services Center for Wellness

BreakingFreeServices.com | [email protected] 1501 S. Pinellas Ave., Suite P, Tarpon Springs, FL 34689 | 727-547-3692

Activities & Interests

What do you do for fun? _________________________________________________________________________

______________________________________________________________________________________________

What kind of music do you listen to? Who’s your current favorite artist/band? ______________________________

______________________________________________________________________________________________

Social

How much time do you spend with your friends? _____________________________________________________

Do you have a best friend? If so, how long have you known him/her? _____________________________________

______________________________________________________________________________________________

Do you feel like you can talk to this person about serious problems? ______________________________________

Do you have a boyfriend or girlfriend? If so, how long have you been dating? _______________________________

______________________________________________________________________________________________

Health

How would you rate your overall physical health? ( ) Good ( ) Okay ( ) Poor

Check all of the following that apply to you:

___ I have headaches once a week or more.

___ I have gained 10 lbs or more in the last 2 months.

___ I have lost 10 lbs or more in the last 2 months.

___ I have difficulty falling asleep.

___ I wake up frequently during the night.

___ I wake up very early and can’t go back to sleep.

___ I feel tired a lot of the time.

___ I have a hard time concentrating.

___ My memory is not as good as it used to be.



Check all of the feelings you often have:

__ Happy __ Sad __ Angry

__ Irritable/”touchy” __ Anxious/Nervous __ Bored

__ Confused __ Confident __ Shy

__ Hyped-up/Energetic __ Guilty __ Depressed

__ Lonely __ Worried __ Worthless

Drug & Alcohol Use

How often do you: Never Tried Monthly Weekly Daily

Drink? ___ ___ ___ ___ ___

Smoke cigarettes? ___ ___ ___ ___ ___

Smoke weed? ___ ___ ___ ___ ___

Use other drugs? ___ ___ ___ ___ ___

Family

Fill in all that apply to you. How well do you get along with your:

Mother: ______________________________________________________________________________________

Father: _______________________________________________________________________________________

Stepmother: ___________________________________________________________________________________

Stepfather: ____________________________________________________________________________________

Brother(s): ____________________________________________________________________________________

Sister(s): ______________________________________________________________________________________

Stepsibling(s): __________________________________________________________________________________

Have there been any major changes in your life in the last five years? _____________________________________

______________________________________________________________________________________________

Is there anything else we should know about you?_____________________________________________________

______________________________________________________________________________________________

Do you have any questions for us? _________________________________________________________________

______________________________________________________________________________________________



Child/Adolescent Intake Questionnaire

To be completed by the parent/guardian

Client’s Name: _____________________________________________________ DOB: ________________________ Age: ________

Reason for Referral

Presenting Problems at Home: ___________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Onset/duration of issue: _______________________________________________________________________________________

Presenting Problems at School: __________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Onset/duration of issue: ________________________________________________________________________________________

School Information

School Name: ________________________________________________________________________________________________

School Address: ______________________________________________________________________________________________

Does your child have an IEP, 504, or other educational plan? (if yes, please provide a copy) __________________________________

Child’s current attitude towards school: ( ) Loves it ( ) Hates It ( ) Indifferent

Has your child skipped or repeated any grades? _____________________________________________________________________

May we contact the school? ( ) Yes ( ) No



Psychiatric History

Has your child ever participated in inpatient or outpatient mental health treatment before? ( ) Yes ( ) No

Dates Location Reason Outcome

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Potential for danger to self: ( ) High ( ) Moderate ( ) Low

Potential for danger to others: ( ) High ( ) Moderate ( ) Low

Medications

Is your child currently on any medications? _________________________________________________________________________

Has your child ever been prescribed medication for psychiatric purposes in the past? _______________________________________

____________________________________________________________________________________________________________

Developmental History

Did the child’s mother experience any complications in pregnancy/while giving birth? ______________________________________

____________________________________________________________________________________________________________

Was there any substance use during the pregnancy? _________________________________________________________________

____________________________________________________________________________________________________________

Was the child born full term? If no, how many weeks premature? ______________________________________________________

Did your child have any difficulties when young, such as speaking/walking/talking/sitting up/potty training/separation anxiety?

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Does the child have any history of cruelty to animals, wetting the bed, or setting things on fire? _____________________________

____________________________________________________________________________________________________________



Family Constellation

For each of the following, please provide name, age, whether living/deceased, education, occupation, marital status, & relationship

with child.

Father: ______________________________________________________________________________________________________

____________________________________________________________________________________________________________

Mother: _____________________________________________________________________________________________________

____________________________________________________________________________________________________________

Siblings: _____________________________________________________________________________________________________

____________________________________________________________________________________________________________

Has the child experienced any of the following?

Event Child’s Age Details

Death of a significant person

Separation from a family member

Physical abuse

Sexual abuse

Emotional abuse

Neglect

Please list methods of discipline/consequence used with the child, consistency, and effectiveness.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________



Has anyone in the child’s family had any of the following challenges?

Challenge Please Explain

Legal

Financial

Marital

Other

Medical History

Has the child displayed or experienced any of the following?

Event Age Details

Significant illness

Hospitalization

Head injury

Accidents

Appetite changes

Sleep changes

Bladder/Bowel Problems



Legal

Has your child had any legal problems? Please explain. _______________________________________________________________

____________________________________________________________________________________________________________

Has your child had any school referrals for misbehavior? ______________________________________________________________

____________________________________________________________________________________________________________

Substance Use

Has your child used any drugs/tobacco/alcohol? If known, please list duration and frequency of use. _________________________

____________________________________________________________________________________________________________

Does anyone in the child’s family have any difficulty with substance abuse?

_______________________________________________

____________________________________________________________________________________________________________

Social & Interests

What are the child’s interests & strengths? _________________________________________________________________________

____________________________________________________________________________________________________________

How does the child get along with their peers? ______________________________________________________________________

____________________________________________________________________________________________________________

Child Custody

If the child’s parents are separated or divorced, please indicate which situation applies:

( ) Joint Custody. Who has primary residence? _______________________________________

( ) Sole Custody: _______________________

If shared visitation, what is the typical visitation schedule? ____________________________________________________________

____________________________________________________________________________________________________________



Signatures

It is the responsibility of the parent/guardian signing this form to notify any other parents/guardians that their child is participating

in counseling.

I certify that the information on this sheet is correct, and hereby authorize Breaking Free Services, Inc. to provide

therapy/counseling, or other psychiatric and/or psychological services as discussed in the preliminary treatment plan necessary for

the client named above. I also authorize the release of medical, psychological, alcohol and drug abuse and psychiatric information

necessary to provide therapeutic services, to collect fees for service from insurers or other third-party payors, and for continuity of

care between Breaking Free Services, Inc and other professionals who also provide services for the client.

Print Legal Guardian Name: _________________________________________________________________

Legal Guardian’s Signature: _________________________________________________________________ Date: _______________



Child/Adolescent Consent for Treatment

To be completed by the parent/guardian

Client’s Name: _____________________________________________________ DOB: ________________________ Age: ________

Consent for Treatment

I certify that I am the parent/legal guardian of the above named child/adolescent and that I do have legal custody of the above

named child/adolescent. I hereby give my authorization and consent for the above named child/adolescent to receive outpatient

assessment/therapy from Breaking Free Services, LLC & its associates.

Divorce/Legal Separation Collection Policy

It is the policy of Breaking Free Services, LLC that the parent/guardian bringing a child/adolescent to our office tor treatment is

responsible for the payment of services rendered at that time. If you have a financial arrangement for the payment of the

child/adolescent medical care, either oral or written, with the child/adolescent’s other parent or responsible party, you will be

expected to pay for the child/adolescent’s care at the time of service and arrange for your personal reimbursement with the other

party. In the event of a true emergency, treatment will not be denied to your child/adolescent.

Print Legal Guardian Name: ________________________________________________ Relationship to Client: __________________

Legal Guardian’s Signature: ____________________________________________________________ Date: ____________________

Witness Signature: ___________________________________________________________________ Date: ____________________



Informed Consent for Treatment

1. Breaking Free Services Center for Wellness, LLC. will provide outpatient counseling, evaluation, information,

and/or referral.

2. No drug or alcohol screening or “search and seizure” methods will be employed.

3. Client is expected to pay for services when services are rendered. If for any reason payment of services is

received back from client’s financial institution (ie, NSF fee from bank) there will be a $20 fee collected prior to the

next appointment.

4. Clients must not be under the influence of alcohol or illegal substances at the time of the scheduled

session. Should client be under the influence of substances other than prescribed medication, the session will be

cancelled by the counselor and the client will be expected to pay for the session at the usual agreed upon fee.

5. Except in cases of emergency, cancellations must be made 24 hours in advance; failure to give 24 hour

notice will be considered a “no show” and billed accordingly, ie, at the usual agreed upon fee.

6. Client’s right to confidentiality will be observed at all times, with the following exceptions:

a. In case of probable imminent danger to self or others.

b. In cases of child abuse, including sexual abuse.

c. Communicable diseases must be reported by the counselor to the appropriate county health department.

d. When you, the client, request that we release information. Information is shared with the other entities

(ie, doctors, insurance companies, etc.) when requested by signing an authorization to release

information form. In accordance with HIPAA privacy regulations, any information shared will reveal only

the basic minimum information necessary. We reserve the right to release only a treatment summary

instead of detailed case notes.

7. A minimum requirement of 72 hours is needed for medical records, once a written request is received.

8. The undersigned will neither individually or jointly involve the therapist or Breaking Free Services Center for

Wellness, LLC. and its staff in any litigation. The undersigned will neither request nor require that Breaking Free

Services Center for Wellness, LLC. or the therapist provide testimony in court. The reason for this is so that

treatment is not compromised, that the therapeutic relationship with the family is maintained, and that the child

can experience their play therapist in a clear, consistent therapeutic role and not as an assessor or detective. If the

services of a mental health professional are desired for court purposes, the services of a person outside of

Breaking Free Services Center for Wellness, LLC. must be enlisted.

9. Counseling Recordings/Artwork: The use of videotaping or photography is sometimes necessary in therapy. Any

type of recording is used to provide feedback to you, the client, or for therapist training purposes. Your

confidentiality is protected and recordings are erased after every session unless your permission is given for

another use. In the case of video or audio taping, you will be informed ahead of time and your written permission

will be needed. The use of photography typically involves pictures of children’s play structures (ie, sand trays,

building blocks, etc.) or pictures of the children with our therapy pet. Children are offered copies of the pictures,

which often helps them extend the therapy program to home and school. Artwork is sometimes used for training

purposes, but the child’s identity is protected. If you have any questions about this, please ask your therapist.

10. Hours of Operation By appointment. Currently days, nights, and weekends are available.



11. After Hours Emergencies In the event of a behavioral health emergency, contact 911 or go to the nearest crisis

center: The Harbor Behavioral Health Center.

12. Payment of Fees or Service We accept cash, check and all major credit cards. Insurance reimbursement is not

available at this time. If a check is returned for insufficient funds, you will be required to pay any bank service

charges in addition to the check amount.

13. Acknowledgement. I authorize the Release of Medical Information necessary for my insurance company to

process my claim. I also authorize the payment of benefits to Breaking Free Services, Inc. I understand and agree

that (regardless of my insurance status), I am ultimately responsible for the balance on my account for any

professional services rendered.

14. Informed Consent. I/we understand the following:

a. That I/we have been fully informed about the nature of the treatment, the risks and benefits, and the

available treatment options.

b. That I/we have had the opportunity to have all questions answered to my/our satisfaction.

c. That this consent is given voluntarily.

d. That I am legally competent and have the authority to provide consent for treatment.

e. That I have the right to withdraw my consent for this treatment at any time.

f. That withdrawing consent for this treatment will not prejudice my continued treatment relationship.

By signing this form, I am acknowledging receipt of a copy of this paper and agreement to the orientation terms

and conditions as provided by Breaking Free Services, Inc.

Print Client Name: ______________________________________________________________________________

Client/Guardian Signature: _______________________________________________________________________

Date: ________________________



Consent to Release Verbal/Written Information

Client Name: _________________________________________________________ Date of Birth (mm/dd/yyyy):_______________

(Last Name) (First Name) (Middle Initial)

Address: __________________________________________________________________________________________________

I, the undersigned, or my legal guardian, hereby authorizes Breaking Free Services to release verbal and/or written information from

my confidential patient file to the following party:

___ Family/Significant Other ___ Facility or Agency Representative ___ Attorney

___ Clergy ___ Therapist or MD ___Other

Name: ________________________________________________________________ Phone: ____________________________

Address: ___________________________________________________________________________________________________

Fax: ____________________________________________________ Email: _____________________________________________

Information to be Released:

___ Billing Information (including dates of office visits)

___ Patient Records (see exception below)

This right is subject to certain legal restrictions. It does not apply to psychotherapy notes or to information compiled for judicial

hearings.

I understand that I have a right to view or get copies of my health information. I understand that the information released may be

mental health or substance abuse related. I understand that I will be charged a reasonable cost-based fee for expenses such as

copies and staff time.

I further understand that the above consent can be withdrawn by me, in writing, at any time. I cannot, however, hold exception to

actions that took place before I withdrew my consent. I understand that the information that is being disclosed is from records

which are protected by Federal Law. Regulation 42-CRF Part 2 prohibits disclosure without the written consent of the person to

whom it pertains.

Client Signature: ___________________________________________________________________ Date: ___________________

Print Client Name: _________________________________________________________________

Witness SIgnature: _________________________________________________________________ Date: ___________________



Documents

General Client Intake Form Client Information (please print)