New Client Form-Therapy Name * First Name Last Name Date of Birth MM DD YYYY Self-Identified Gender * Male Female Non-Binary Prefer not to answer Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone * (###) ### #### Preferred Email * Relationship Status * Single In a relationship Engaged Married Separated Divorced Widowed Race/Ethnicity: * Religious Affiliation: * Occupation Employer Medical History: Please include: Previous/current medical diagnoses and/or if taking medications (specify if from physician or self-diagnoses) * Counseling History: Please include names of therapists (specify if previous or current) * Person responsible for payment: If self, please type your name. If someone else, please type their name and phone number. Please note that they will have to agree to our payment policy in order to charge them for your sessions. If they do not have that on file, you will be responsible for any payments due. * Payment Policy: Please type your full name to show that you understand that you are ultimately financially responsible for any balance. Better Connection Couples Therapy does not bill to any third party payers nor will we provide any information other than receipts of payment made by you to you should you decide to seek reimbursement for our services. We will obtain payment at the time of service or in the case of a late cancellation or no-show. * CANCELLATION POLICY: Type your FULL NAME here to confirm that you agree to being charged the full session fee if you do not give our office greater than 24 hours' notice should you choose to reschedule or cancel your appointment. * How did you hear about Better Connection Couples Therapy? * Emergency Contact and Phone Number: We will only contact this individual with your consent or without your consent should there be a threat to your physical safety. We may also choose to call upon 911 Emergency Services and all costs incurred will be your responsibility. * Please type your FULL NAME to indicate you have read and understand this statement: The outcome of my treatment depends on my willingness to engage in the therapeutic process honestly. I understand that at times this might cause uncomfortable feelings as I discuss difficult experiences and past memories/trauma. I understand that there is no instant cure when it comes to therapy. I understand that my therapist will provide me with support, understanding, validation, and assistance in understanding my patterns. * Please type your FULL NAME to indicate you have read and understand this statement: The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: 1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm. 2. If a client threatens grave bodily harm or death to another person. 3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years. 4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. 5. Suspected neglect of the parties named in items #3 and #4. 6. If a court of law issues a legitimate subpoena for information stated on the subpoena. 7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney. 8. If the client discloses that he/she or any other named victim has been the victim of emotional, physical or sexual misconduct by a current/previous psychotherapist, the therapist will report any incidences to the appropriate Board. * Please type your FULL NAME to indicate you have read and understand this statement: All payments will be processed through QuickBooks via credit or debit/pre-paid cards. Payments will be processed at the end of the therapy session. * Clients must seek the written permission of the therapist before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook or YouTube. Your therapist cannot become friends with clients on social media, however you are welcome to follow our account @THETHERAPYTIMES for therapy content. Better Connection Couples Therapy uses Google Meet for messaging and video communications to allow for the highest possible security and confidentiality of the content of your sessions. In order to benefit from these safeguards, the client is required to download, register and utilize the chat and video software from Google Meet. Your personal information is encrypted and stored on a secure server in compliance with HIPAA regulations. * Please type your FULL NAME to indicate you have read and understand this statement: Better Connection Couples Therapy recommends contacting local emergency services (ex. "911"), a crisis line, or an agency local to the client. Clients may utilize the following crisis hotlines in the United States: 1-800-SUICIDE or 1-800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY). * Thank you!
