Intake & Consent Form Intake & Consent Form Each member of a family or couple is required to fill out their own form. CompanyThis field is for validation purposes and should be left unchanged.Today’s Date(Required) CLIENT INFORMATIONClient’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) Age(Required)M/F(Required) M F Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed 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#1Name of Local Friend or Relative (not living at same address)Relationship to ClientHome Phone No.Work Phone No.#2Name of Local Friend or Relative (not living at same address)Relationship to ClientHome 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 FORMI 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) 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) 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) 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 Δ
