Office Directions to ACA Counseling 3247 Electric Rd., sw Suite lA (Building F)

From Salem, go up Electric Rd (Rt 419) towards Tanglewood Mall. Go thru the light at

Rt 419 and Brambleton Ave. (Cave Spring Corners) and take the FIRST RIGHT into the Cave

Spring Professional Center. (If you go to the stoplight at Ruby Tuesday, you have gone too far)

We are the first building on the left (Across from Wheelock and Johnson Orthodontist).

From Roanoke, go up Electric Rd (Rt 419) from Tanglewood mall TOWARDS Salem.

Go thru 7 lights. At the 7th stoplight (approximately 2 miles) there w ill be a Ruby Tuesday on

your right . Go THROUGH that light and the next immediate LEFT into Cave Spring Professional

Center. (If you get to Rt 221/ Bambleton Ave. at the corner with a Sun Trust Bank on your left

and a Goodwill on your right, you have gone too far). Once you turn into Cave Spring

Professional Center, we are the first building on the left.

ACA COUNSELING SERVICES 3Z47 ELECTRIC ROAD, SUITE 1-A

ROANOKE, VA.24018 (540) 772-0690

PATIENT INFORMATION ·SHEET A.ND

CONSENT FOR TREATMENT

Patient's Name--------------------- Home Phone:...._,...._ ____ _

First Middle Last

Patient's Address: ________________________________ _

Street City State Zip Code

Patient's Social Security Number: Patient's Birthdate: ___ _ Patient's Relation to Responsible Party: __ Self __ Spouse __ Child __ Other Patient's Marital Status: __ Single - ·- Married __ Widowed __ Divorced -. _ Patient's Gender: Female · Male

Referral Source:-------------------- Phone: ----------First Last Address

Patient's.School/Employer:--------------- Phone:-----------­Employer's Address:----------~------ Work Phone:-----------Spouse's Name: Social Security Number:---------Spouse's Employer: Work Phone Number:---------Person to Notify in Case of Emergency: Phone Number:---------"--Number you Prefer to be Notified of Scheduling Issues/ Appointments:--------------Do you wish to be contacted by this office by phone? YES NO

IF PATIENT IS A MINOR, PLEASE GIVE THE FOLLOWING INFORMATION:

Father's Name:------------- Social Security Number:------------

Father's Employer:------------ Phone:-------------

Mother's Name:------------ Social Security Number:------------

Mother's Employer: Phone:-------------Parent's Marital Status: __ Single __ Married __ Widowed __ Divorced

Guardian's Name: Social Security Number:--------Guardian's Employer: Phone Number:-----------

INSURANCE INFORMATION: Primary Insurance: Policy Number:----------lnsured's Name (if other than patient): Group Number:--------Secondary Insurance: Policy Number:-----------lnsured's Name (if other than patient): Group Number:---------

PLEASE SIGN AND REAJ? THE BACK.

CONSENT FOR TREATMENT 1 understand that my insurance policy is a contract between the insurance company and myself. 1 acknowledge and agree that I am personally responsible for the Immediate payment for services rendered in this office. I authorize the re.lease of any informat!On that is necessary to process claims that have been filed with my insurance company, or to obtain further Information if required. I also endorse any payments from government . benefits (if applicable to me) for services provided to the Clinician. I authorize payment of medical or therapy benefits directly to the Clinician for services rendered.

If a referral is required by my insurance company to pay for services provided, it is my responsibility to obtain the document. Otherwise, I will be financially liable should my insurance company deny these services. Should provided services extend beyond the services authorized by my carrier, I will be responsible for the balance due.

APP QIN TM ENT S CAN CELLE _D WITHIN LESS THAN 2 BUS INES S DAYS 0 F MY SCH EDU LED T 1.M E

WILL BE BILLED DIRECTLY TO ME FOR THE FULL FEE OF THE SCHEDULED APPOINTMENT.

There are certain circumstances that if mutually agreed upon, may result in waiving of the missed appointment fee. This can be discussed with my Clinlcian in my next scheduled appointment.

We accept payments in cash, personal check, money order, and major credit cards. Unfortunately, we .cannot accept post-dated checks. Returned checks are assessed a $35.00 processing fee to cover related accounting and banking expenses incurred to us.

Patient's Signature (or Parent, if minor) Date

If I am a Medicare participant, I request that payment under the Medicare Insurance Program Is made on my · behalf to the Clinician for any services rendered by the Clinicians therein. I authorize any holder of medical information about me to release Medicare and its agents any information needed to determine those benefits · of the benefits payable for related services.

Beneficiary's Signature (For Medicare clients only) Date

ACA COUNSELING SERVICES

3247 ELECTRIC ROAD, SUITE 1-A . ROANOKE, VA. 24018

(540) 772-0690

Welcome to ACA Counseling Center, a group of independently affiliated mental health care providers. We are located at Cave Spring Professional Center. Our mission is to provide the highest quality psychological services for children, adolescents, adults and families In the Roanoke Valley. We hope this handout will answer

·many of your questions about our services. Please feel free to discuss any questions or concerns with us. Thank you for the opportunity to serve you.

APPOINTMENTS: Our services are by appointment only. You may contact our office manager at (540) 772-0690. You will

be required to complete various forms to provide background information related to your requests for services. It is essential that all forms be signed, especially by parents or legal guardians, for treatment of a minor. These forms must be brought with you to the first appointment. Parents/legal guardians M..!:!ll accompany minors to this appointment.

The initial appointment, also called a diagnostic interview, will be 50-60 minutes in length. Subsequent therapy sessions are generally scheduled for 45-50 minutes ("the clinical hour"). Sessions that extend beyond this time period will be billed at a pro-rated amount. Other psychological services may vary in length of treatment time. Please be aware that it is impossible to meet the scheduling needs of every client. Appointments are scheduled on a first-come, first-serve basis. If you have particular schedule needs, you must reserve appointments in advance and in conjunction with your provider.

Your scheduled appointment time is reserved exclusively for you. As such, we require Two Fu LL

s us 1 N Es s o Av s to cancel this appointment. For example, if your appointment is at 9 a.m. on a Monday, we ask that you call the Thursday before the scheduled appointment prior to 9 a.m. Failure to cancel this appointment in a timely manner means that someone else will not be able to use this time. It is our policy to charge for a missed appointment or a late cancellation (less than 2-business day notice). Insurance companies do not reimburse missed appointments, and these charges will be billed directly to you. Emergency circumstances do occur, and you will not be charged for an absence that both of us would define as an emergency. We do require a phone call prior to the appointment, however, or you will be charged. Repeated failures to show for appointments may result in interruption or termination of treatment.

FEES:

Initial Intake $100-$150 Therapy Sessions $80-$120 Family Sessions $80-$120 Psychological Testing $110-$120/hr. Court Appearance $150-$300/hr. No Show-Late cancel Charge will be according to service Letter Writing Fee $10 Report Writing Fee $100/hr. Telephone Consultation $100/hr. after initial fifteen minutes Copying Charge $10 preparation fee and $0.50/page Return Check Fee $35 Insurance Research Fee $25/hr.

PAYMENT IS EXPECTED AT THE Tl ME OF SERVICE. If you choose to use an insurance company for partial reimbursement, please be aware that your contract Is between you and your insurance company. We cannot guarantee your insurance coverage or benefits. You remain financially responsible for these charges. We do require completed insurance information and a copy of your insurance card to verify benefits. We ask that you preauthorize any treatment with your insurance carrier and/or physician, and we will also contact your insurance company to verify authorization. We will file primary insurance claims for you. We do require payment in full at the time of service for co-payments, deductibles, and any charges not reimbursed by your insurance carrier. OUTSTANDING CHARGES OVER 60 DAYS WILL BE ASSESSED WITH A FINANCE CHARGE OF 1. 5 %. Failure to make payments in a timely manner may result in the use of a collection agency with your account: Be aware that this situation will affect your credit report and your ability to receive these services in . the future. If you are having difficulty with payment and would like to discuss a payment plan, please contact our office manager. Some therapists do accept credit cards for your convenience. We ask that you make out your check in the name of the provider with whom you are working. Please discuss any questions about these policies with our staff.

RELEASE OF INFORMATION: Information regarding our clients is treated as strictly confidential. We will not release any information

without specific written authorization as mandated by HIPPA requirements, except for the following reasons: 1. In case of suspected child abuse or abuse/neglect of a disabled adult, we are legally mandated to report

it to the proper authorities. 2. When a client is judged to be a serious threat to himself/herself or others, the clinician has the legal

responsibility to report the threat to the appropriate person. 3. We must comply with a court order for the release of records. 4. In the event of a crisis during the absence of your therapist, it may be necessary for other clinicians to

have access to your records in order to assist you in the best possible manner. 5. In some instances, your insurance carrier may require diagnostic and/or treatment information before

authorizing services and providing reimbursement. We will release that information to them with your written permission. Be aware that we no longer have control of the confidentiality of that information, once it has been released from our office. If you prefer to not have that information released, you must inform us of your wishes in writing. Should your Insurance carrier fail to authorize or reimburse services, you remain responsible for the fee for services. Verbal/telephone requests for release of confidential information will not be filled.

DEPENDENT CLIENTS: Please be aware that we require written permission from the legal guardian of a minor to provide

services to this minor. If there is joint legal custody, we must have the signature of both guardians. We cannot provide treatment without theses signatures. The parent bringing the child for treatment will be required to sign all forms and will be held responsible for ill financial charges, regardless of any financial arrangements made between the parties. Parents must also be aware of our policy regarding confidentiality. As the therapist of a child it is most important that we create a trustworthy atmosphere and provide this child with complete confidentiality. Parents, however, do have the right to information concerning the treatment activities and progress of treatment with the child. In addition, the courts of Virginia have judged that non-custodial parents have the right to receive information concerning the child's psychological status. Because this is a delicate issue, please discuss any of your concerns about confidentiality prior to treatment.

EMERGENCY SITUATIONS:

In the event of an emergency, please contact our office immediately to speak with the secretary or leave a voice-mail message for your therapist. Be aware that our phone system is not a 24-hour crisis line, and your message may not be received until the next working day. If this is a life-threatening emergency, you will

need to proceed to the emerg~ncy room of your local hospital. You may also contact a 24-hour crisis line

{RESPOND: (540 776-1100 or CONNECT: (540) 981-8181). Please be as specific as possible when leaving a message with our office, including where and when you may be available for a return call.

LETTERS : Letters and reports to be written at the request of the client will be charged to the client. This includes

family leave forms, Homebound Instruction forms, and disablllty forms. This payment must be received prior to the mailing/faxing of this document .

TELEPHONE CONSULTATIONS: We understand that important issues may arise between sessions. If at all possib le, we request that you

bring these issues directly into the t herapy session, where we might address them with sufficient time. Please reserve your calls between sessions to emergencies or urgent situations. Due to the volume of phone calls, please understand that we must return them on a priority basis throughout the week. Phone consultations over 15 minutes in length will be charged to the cl ient (see fee schedule).

COPYING POLICY: If you, or someone on your behalf, request the copying of your records or a specific document, we

require your WR ITTEN authorization for the release of these records. Please check the fee schedule for the charges for this service. The cl ient is responsible for these charges and must pay prior to t he release of these records.

COURT APPEARANCE P OLICY : While our priority is to treat your psychological needs within the therapy session, occasionally your

records or your therapist may be requested or subpoenaed to court on .your behalf. Be aware that the charges for court appearances or legal consultations will be billed directly to the client. Insurance companies will not reimburse these charges. Charges will include t he t ime preparing and spent in court, time away from the office, as well as mileage and parking fees.

PAYMENT FOR DAMAGE S TO THE FACILITY: Clients and parents are financia lly responsible for any damages to our facility or its contents. Please

help us in maintaining a clean and orderly environment for your comfort.

QUESTIONS OR CONCERNS: If you have any questions or concerns about these policies, please speak with your therapist or our

secretary as soon as possible. We welcome all feedback and suggestions for improvement with our services.

Please sign below that you have read, understood, and accept the above policies.

Client's Printed Name Date

Client's Signature Parent/Legal Guardian Signat ure

ACA COUNSELING SERVICES

3247 ELECTRIC ROAD, SUITE 1-A

ROANOKE, VA. 24018

(540) 772-0690

HIPAA NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information . Please review it carefully. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by the law. It also describes your rights to access and control your own protected health information. "Protected health information" is information about you, including demographic information , that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services.

1. USES AND DISCLOSURES OF PROTECTED HEAL TH INFORMATION

Your protected health information may be used and disclosed by your provider, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services, to you, to pay your health care bills, to support the operation of the physician's practice, and other uses required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. Th is includes the coord ination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay or treatment services may require that your relevant protected health information be disclosed to the health plan to obtain approval for the services.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your provider's practice. These activities include, but are not limited to, quality assessment activities, employee review actions, train ing of students, licensing and conducting or arranging for other business activities. For example, we may use a sign-in sheet at the registration desk where you wi ll be asked to sign your name and indicate your physician/provider. We may also call you by name in the waiting room when your provider is ready to see you. We may use your protected health information , as necessary, to contact you to remind you of your appointment.

We may use your protected health information in the following situations without your authorization. These situations include: Public Health Issues as required by the law; Communicable Diseases; Health Oversight; Abuse or Neglect; Legal Proceedings; Law Enforcement; Coroners, Funeral Directors, and Organ Donation; Research ; Criminal Activity; Military Activity and National Security; Worker's Compensation; Inmates. Required Uses and Disclosures: Under the law, we must make disclosure to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted Uses and Disclosures: Will be made only with your Consent, Authorization, or Opportunity to Object unless required by law.

2. REVOKING AUTHORIZATION

You may revoke this authorization at any time, in writing , except to the extent that your provider or the provider's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

3. YOUR RIGHTS

Following is a state of your rights with respect to your protected health information:

Inspect and Copy: Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil , criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

Right to Request Restriction of your PHI: This means that you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your provider is not required to agree to a restriction that you may request. If the provider bel ieves it is in your best interest to permit use and disclosure of your PHI , your PHI will not be restricted . You then have the right to use another Health Care Professional. ·

You have the right to request to receive confidentia l commun ication from us by an alternative means or at an alternative location . You have a right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively (i .e., electronically) .

You have the right to have your provider amend your PHI. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and wil l provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosure we have made, if any, of your PHI. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been vio lated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and became effective on/before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information . If you have any objections to this form, please speak with our HIPAA Compliance Officer in person or by phone at our office phone number.

Signature below is only acknowledgment that you have received this Notice.

Client Printed Name Client/Parent or Legal Guardian Signature

Date

ACA COUNSELING SERVICES

3247 ELECTRIC RD., SUITE 1-A

ROANOKE, VA 24018

NAME OF PATIENT: ______________ _

DATE OF BIRTH: ________________ _

APPOINTMENT NOTIFICATIONS

We welcome you to ACA Counseling Services. As part of your involvement in professional services with us, we provide "courtesy reminders" of your scheduled appointments. This form indicates the means by which our office will provide you the "courtesy reminder." We will provide such reminders by electronic communication via our EHR. If you do not wish to receive such reminders in this format, you will be responsible for attendance at the scheduled appointments and will accept responsibility for any fees incurred due to late cancellations and/ or not showing for appointments.

I agree to email reminders via EHR ___ (initials)

Email to be used: ~~~~~~~~~~~~~~~~~~~~~~--

Any changes in the manner of contact or email address are~ responsibility and must be presented in writing and signed by you to our Office in a timely manner. We will continue with the designated approach and email if changes are not communicated to us in this manner. Your signature on this form indicates your permission for ACA Counseling to communicate with you in this manner.

Signature

Date

0 ACA Counseling Services 324 7 Electric Road, Suite 1-A ( Roanoke, Va. 24 018 ( (540) 772-0690 I acacounselingroanoke.com

Adult Intake Form Name:

I Today's Date:

Street: Suite/ Apt. #:

City: State: Zip Code:

Home phone number: Date of Birth:

Work phone number:

Mobile phone number:

Race: I Religion: Gender

Person to call in case of emergen cy: Relationship to Client:

Address:

Home Phone Number: Cell Phone Number:

Name of referral sou rce:

Name ofphysician(s): Address: Phone number:

Date of last physical examination:

Type of residence (Please Check):

House 0 Dormitory 0

Hotel Apartment 0 0

Hospital Room 0 0

0 Other

Marit al Status (Please check those that apply):

0 Never married 0 Separated If married, how many times? 0 Married 0 Widow /Widower If divorced, how many times? 0 Divorced 0 Marriage annulled 0 Living cooperatively 0 Other

Occupation:

· Years at current job

Prior job?

Education (Please specify highest level completed by circling applicable answer):

6th grade 9th grade 11th grade

High School and earlier:

7th grade 10th grade 12th grade

8th grade

College/University

1 year 2 years 3 years 4 years S years Other

Bri~fly describe the problems that have led you to seek counseling.

Adult Intake Form, page 2

BA

Graduate School

BS MBA

MA Ph.D.

MS Other

Please list any physical symptoms related to and/or any way your life has been affected by the above problems.

Check any of the following areas that are stressful for you at this time:

o Family problems o Work problems o Marital problems o Financial problems o Sexual problems o School problems

Adult Intake Form, page 3

How long have these problems been present? What have you tried to correct the problem?

Have you had previous counseling about these problems? If yes, with whom?

Are you presently under a doctor's care for any condition? If yes, name the condition.

Please list immediate family members : Name Relationship Status Age Occupation

Suicide:

0 Check here if you have ever thought about suicide. If yes, when was the last time?

0 Check if you have ever attempted suicide. If yes, when and how?

0 Check if you have thoughts about suicide now.

Injury to others:

0 Check if you have ever thought about hurting someone else. If yes, when was the last time?

0 Check if you have ever hurt someone else. If yes, when and how?

0 Check if you are thinking about hurting someone now.

Review of your coping/functioning: Check any of the following that have caused concern or difficulties during the last 6 months.

0 Taking care of personal grooming needs 0 Meeting "home" responsibilities

Taking care of children or others 0 Meeting "work" responsibilities 0

0 Getting along with significant other 0 Enjoyment of hobbies

Getting along with children 0

0 Prepares meals for family/ self 0 Getting along with co-worker and others

Meeting financial obligations 0 When was the last time you went to school or to

0

your job?

Medical History:

Weight/Height: Current weight (pounds) ---- - -----

Maximum weight (as an adult)---------

Menstrual History:

Age at first period------------

Irregular periods? Yes ___ __ No ____ _

Last period started (Month/Day): --------

Are you pregnant? _____ _______ _

Do you take birth control pills?-------

Do you use another contraceptive?------­

Have you had any miscarriages? - -------

Who is your personal physician?

Name:

Address:

Phone number:

When was your last complete physical examination?

Are you presently taking any medications?

Adult Intake Form, page 4

Height (inches)------------­

Minimum weight (as an adult)--------

Menopause age _ ____________ _

Average period duration---------­

Do you have mood changes related to your period? _

Are you attempting pregnancy? ________ _

If so, what is the name of the me dication? ____ _

Please specify what kind. ----------­

Have you had any abortions?---------

If yes, please list the medications, dosages, and who prescribed them.

Adult Intake Form, page 5

Medical History (continued):

Check if you have trouble with:

0 Falling asleep

0 Falling back to sleep

0 Tired upon waking

0 Early morning awakening

0 Bad dreams

When do you usually go to bed?

When do you usually wake up?

How many cups of caffeine do you have per day?

_____ cups of coffee

_____ cups of tea

_____ cups of soda

Please list any known drug allergies if applicable.

Medication

0 Nightmares

0 Wetting the bed

0 Sleep-walking

0 Snoring

0 Falls asleep when emotional

Do you smoke?

If so, how many packs per day?

At what age did you begin smoking?

o Check if you're sensitive to caffeine.

Reaction

o Please check if you have concerns about your eating behavior.

If so, have you ever restricted your eating for long periods?--------

Have you ever purged after eating excessive amounts of food in short periods of time? -------

Please feel free to use the space below for any additional comments.

Adult Intake Form, page 6

Do you regularly (Circle fl]] that apply): Drink alcohol Smoke Use non-prescribed drugs

If you do, does your habit: hurt your relationship with others? hurt your job?

Is it difficult for you to stop or co ntrol the amount you take?

Is there any history of alcohol or drug abuse in your family?

Who in your family has had a problem with drugs or alcohol?

Does your temperament change when you drink? Ifso, how?

Is there any history of violence, verbal or sexual abuse in your family?

Substance Frequencyinlastyear Age of first use Date of last use

Alcohol

Barbiturates (without doctor knowing) Xanax, Valium, Librium

Cocaine, Crack

Heroin, Opiates

Marijuana, Pot

PCP, LSD, Mescaline

Inhalants

Caffeine

Nicotine

Amphetamines, Speed, Uppers Designer Drugs, Ecstasy

Over-the-counter meds

Others:

Describe when and where you typically use.

Describe how your use has affected your family or friends, including how they perceive your use.

Do you use to build up your confidence?

What is your perception of your use?

Who in your family (present/past) has had a problem with drugs or alcohol?

Have you ever had the following?

0 Blackouts 0 Hallucinations 0 Seizures 0 DUl's 0 Tremors 0 Legal charges

Adult Intake Form, page 7

Check any of the following symptoms you have had and the severity.

Current Past Current Past

CJ bl Depressed Mood/Excessive Worry bJ ld Periods of unconsciousness

D bl Lack of interest in pleasure CJ CJ Epilepsy /seizures

CJ [J Loss of energy kJ bl Recent weight gain/loss (Amount:

bl CJ Feeling of worthlessness CJ a Sweating

bd b1 Feeling hopeless CJ [l Trembling

D CJ Difficulty getting to sleep D CJ Slurred speech

CJ CJ Difficulty staying asleep CJ CJ Asthma

bJ bl Feeling restless rd Cl Allergies/Hay Fever

CJ CJ Low self-esteem D CJ Hepatitis

0 CJ Increase in agitation CJ CJ Diabetes

CJ D Fear of separation CJ D Abortion/Miscarriage

CJ CJ Poor attention/concentration D CJ Magical Thinking

0 0 Tearfulness D 0 Excessive sense of orderliness

D .bl Feeling grandiose CJ CJ Excessive cleaning

D bl Racing thoughts bl 0 Frequent counting

CJ 0 Physically hurting yourself 0 0 Hoarding/collecting

0 Cl Anxiety CJ bl Checking behaviors

0 CJ Lying/stealing 0 D Repetitive behaviors

bl CJ Distractibility 0 CJ Tumor /Growth/Cyst/Cancer

CJ EJ Memory Problems 0 ld Arthritis/Bursitis/Rheumatism

CJ D Reckless bl 0 Shortness of breath

bJ 0 Withdrawn from friends D 0 Chest pain

CJ D Not following rules/laws CJ bJ Fear of losing control

Cd bl Feeling guilty CJ CJ Fear of dying

CJ 0 Feeling helpless D CJ Panic attacks

CJ 0 Marked mood shifts CJ Cl Easily fatigued

D bl Increase in feeling irritable D CJ Fear of leaving home

CJ bl Frequent/severe headaches CJ CJ Fear of being in a crowd

CJ D AJDS/H!V CJ bl Intruding thoughts

CJ D Dizziness/fainting/light-headed 0 0 Food restriction

[] LJ Loss of memory/ Amnesia D LJ Change !n appetite

Adult Intake Form, page 8

Check any of the following symptoms you have had and the severity.

Current Past Current Past

.bl b] Binge eating bl Cl Hearing problems

CJ bl Self-induced vomiting 0 bl Menopause

bl bJ More talkative than usual D. CJ Stutter/stammer

CJ CJ Impulsive [d bl Double Vision

bJ bJ Disorganized bl [J Head Injury

Cd D Indecisiveness D bJ Prostate troubles

bJ bJ Hyperactivity D D Frequent urination/painful urination

0 bJ Rheumat ic Fever D bJ Chronic Pain

D D Chronic/frequent colds, coughs bl w Anemia

CJ CJ Coughing up blood bJ bJ Stroke

a D Skin disease D D Kidney Problems

Cl CJ Venereal disease D c:J Neurological Problems

[d 0 Numbness/tingling bJ [] Drug Allergies

Cd Cd Cardiac Problems/Pounding Heart Cl bl High/Low Blood Pressure

bl CJ TB bJ D Pain/pressure in chest

bJ CJ Scarlet Fever CJ CJ Thyroid trouble

bl bJ Fever/ Chills Cd bl Excessive sweating

D D Eye, ear, nose or throat problems D Cl Gastrointestinal problems

Family History: Please check those that apply.

Father Mother Brother Sister Grandparent Extended fa mily

Substance Abuse:

Diabetes:

Cancer:

High Blood Pressure:

Heart Problems:

Depression:

Anxiety:

Attempted Suicide:

Suicide:

Adult Intake Form, page 9

Personal history: Check items that apply

o Mother's pregnancy with you was abnormal

o Mother's delivery of you was abnormal

o Circumstances of pregnancy/ delivery are unknown

o Check if you were adopted into your family

o Age when adopted:------------

o What is your birth order? ___ of __ _ siblings

Please use blank space for extra comments to help therapist.

Childhood problems:

o Check if your parents separated during childhood

o Check if parents divorced during childhood

o Your age at separation/divorce? _ _____ _

o Check if your mother remarried.

o Check if your father remarried.

Relationship with Mother: o Good o Fair o Poor o Abusive Relationship with Father: o Good o Fair o Poor o Abusive Relationship with Step-Mother: o Good o Fair o Poor o Abusive Relationship with Step-Father: o Good o Fair o Poor o Abusive

Check items that apply

0 Fear of school 0 Bed wetting after age 5

0 Nausea/Vomiting before going to school 0 Tics (involuntary movements or gestures)

0 Difficulty reading, writing and/or with math 0 Nightmares or night terrors

0 Skipping classes or cutting school 0 Poor eyesight

0 School failures/repeating grades 0 Mispronounced words/lisped

0 Accidents or accident-prone 0 Slurred words or stutter

0 Awkwardness at games 0 Sleep disturbances

0 Ran away from home 0 Was exposed to childhood sexual abuse

0 Cruelty to animals 0 Was exposed to childhood emotional abuse

0 Lying to family or others 0 Was exposed to childhood physical abuse

0 Fire setting 0 Prior history of sexual promiscuity

0

Adult Intake Form, page 10

Marital history: o Please check if never married.

Please name your current spouse or significant other below.

Number of years together? _____ _ Quality of relationship? ----------

Please name your ex-spouse below (if applicable).

Number of years together? _____ _ Quality of relationship? ----------

Please name your ex-spouse below (if applicable) .

Number of years together? _ ____ _ Quality of relationship?---------

Please name your ex-spouse below (if applicable).

Number of years together? _ ____ _ Quality of relationship? _________ _

Current family: o Please check if you do not have any children.

Please list all children in the space below.

Name Age Grade/School Who is the other parent?

Adult Intake Form, page 11

Leisure /Recreational: Describe special interests or hobbies.

Art:

Music:

Crafts:

Books/Film:

Physical Fitness:

Diet/ Health:

Sports:

Outdoor Activities:

Church Activities:

Other:

Has your activity level changed recently? If yes, please describe:

Counseling/Prior Treatment History:

Yes No When Where Br iefly Describe

Psychiatric Counseling

Suicidal Thoughts

Drug/ Alcohol Treatment

AA/NA/ Al-Anon/Self Help

Hospitalizations

Military (Circle one) : Yes No

Branch: Discharge Date:

Other items or issues your therapist should know:

Thank you for taking the time to give us the above information to better serve you.

I have received the Adult Intake Form for ACA Counseling Services: