Intake & Consent Form
Each member of a family or couple is required to fill out their own form.
Today’s Date
(Required)
MM slash DD slash YYYY
CLIENT INFORMATION
Client’s Name
(Required)
First
Middle
Last
Title
(Required)
Mr.
Ms.
Marital Status
(Required)
Single
Married
Partnered
Other
Gender
(Required)
Male
Female
Transitioning
Other
Sexual Orientation
(Required)
Heterosexual
Bisexual,
Lesbian
Gay
Other
Birth Date
(Required)
MM slash DD slash YYYY
Age
(Required)
M/F
(Required)
M
F
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone No.
(Required)
Cell Phone No.
(Required)
Do you have children, how many and what are their ages?
(Required)
Occupation
(Required)
Email Address
(Required)
IN CASE OF EMERGENCY
#1
Name of Local Friend or Relative (not living at same address)
Relationship to Client
Home Phone No.
Work Phone No.
#2
Name of Local Friend or Relative (not living at same address)
Relationship to Client
Home Phone No.
Work Phone No.
Please state reasons for coming in. List or explain any relevant information that your therapist should know. Continue on next page if necessary: If you are in a relationship, please say how many months or years and when you met? If married or living together, please let me know how long?
(Required)
CLIENT INTAKE FORM
I understand that I am responsible for my fee payment at the beginning of each appointment. I agree to be responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought.
CLIENT/GUARDIAN SIGNATURE
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
I hereby consent to treatment by Jeannette York. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have a right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.
CLIENT/GUARDIAN SIGNATURE
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
I understand that the policy of this therapist is that all scheduled appointments must me cancelled 24 hours in Advance or the full fee will be due. Cancellation must be made by a phone call or email within 24 hours of appointment time.
CLIENT/GUARDIAN SIGNATURE
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
DISCLOSURE STATEMENT & AGREEMENT FOR SERVICES
Your therapist is a: Licensed Marriage and Family Therapist / CA License # 47797 and SC # 4612
Jeannette York, MFT, MA
210 Pass Avenue, Burbank, 91505
Fees and Insurance
The service fee is $235.00 per 55-minute session.
The service fee is $250.00 per couple or family per 75-minute session.
If I am seeing you on Zoom, fees should be sent before the session to Venmo, or Zelle. If we are meeting in the office you can also use cash, check or credit card. Zelle can be sent via 818 200 9513 or Venmo can be sent to Jeannette-York-1
Confidentiality
All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release. (In addition, your therapist will not disclose information communicated privately to him or her by one family member, to any other family member without written permission.)
There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder abuse. Therapists may be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself.
Appointment Scheduling and Cancellation Policies
Your consistent attendance greatly contributes to a successful outcome. In order to cancel or reschedule an appointment, you must notify your therapist at least 24 hours before your appointment. If you do not provide your therapist with at least 24 hours’ notice in advance, you are responsible for payment for the missed session
Therapist Communications
Your therapist may need to communicate with you by telephone, mail, or other means. Please indicate your preference by checking one of the choices listed below. Please be sure to inform your therapist if you do not wish to be contacted at a particular time or place, or by a particular means.
My therapist may call me on my cell phone.
(Required)
Yes
No
My cell phone number is:
(Required)
My therapist may communicate with me by email.
(Required)
Yes
No
My email address is:
(Required)
Termination of Therapy
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. You may discontinue therapy at any time. Your signature indicates that you have read this agreement for services carefully and under- stand its contents. Please ask your therapist to address any questions or concerns that you have about this information before you sign.
Name of Patient
(Required)
First
Last
Date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
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