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Adult Intake Form

Patient intake Form
Marital status
Date of marriage
Date of separation (if applicable)
Place of employment and address
Whom may we thank for referring you?
Name
Family Information
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Name, DOB, Relationship(e.g., spouse, child, step-child), Currently Living (in or out of home)
Medical Information:
What is your present health condition?
What is your present health condition?
Date of most recent physical examination:
Please list your medications below, beginning with current medication, and working backward:
Dates, Names of Medication, Amount, Taken When, Prescribed by, Your Reaction
Dates, Names of Medication, Amount, Taken When, Prescribed by, Your Reaction
Dates, Names of Medication, Amount, Taken When, Prescribed by, Your Reaction
Dates, Names of Medication, Amount, Taken When, Prescribed by, Your Reaction
Dates, Names of Medication, Amount, Taken When, Prescribed by, Your Reaction
Dates, Names of Medication, Amount, Taken When, Prescribed by, Your Reaction
SOCIAL ADJUSTMENTS: How would you describe your interpersonal relationships?
PRESENTING PROBLEMS:

PART 1: PATIENT RIGHTS

1. You have the right to a confidential relationship with me. Within certain legal limits (see #4 below), information revealed by you during the course of therapy will be kept completely confidential and will not be revealed to any agency
or other person without your written permission.
2. You have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances.
3. If you ask for it, any part of your records on file with me can be released to any agency or person you specify. I will inform you at the time of your request whether or not I think releasing that information to that agency or person might be harmful to you in any way.
4. Under certain legally defined situations, I am required to reveal information given during the course of therapy, including E mail and text message communication, to other agencies or persons without your written consent. I am not, however, required to inform you of my actions if this occurs.
a) If you reveal information to me about child abuse, or neglect or physical abuse of a dependent adult or an elderly person, I am required by law to report this to the appropriate authority. I will direct you to report spousal abuse.
b) If you threaten bodily harm or death to another person I am required by law to warn the intended victim and notify the appropriate law enforcement agencies.
c) If you threaten bodily harm or death to yourself, I am required by law to refer you immediately to an inpatient psychiatric program.
d) If you are in therapy or being tested by order of a Court of law, the results of the treatment or tests ordered must be revealed to that Court.
e) If a Court of law issues a legitimate subpoena, I am required by law to provide
the information specifically described in the subpoena.
5. You have the right to ask questions about any of the procedures used in the course of therapy. If you ask, I will explain my customary approach and methods to you.
6. You have the right to choose not to receive therapy from me. If you choose this, I will provide you with names of the other qualified professionals whose services you might prefer.
7. You have the right to terminate therapy with me at any time without any financial, legal or moral obligations other than those you have already incurred.

PART II: THE THERAPY PROCESS

Participation in therapy can result in a number of benefits to you, including a better understanding of your personal goals and values, improved interpersonal relation ships, and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part and may result in your experiencing considerable discomfort.
Remembering and resolving unpleasant events through therapy can bring on strong feelings of anger, depression, fear, etc. Attempting to resolve issues between marital partners, family members, and other individuals can also lead to discomfort and may result in changes that were not originally intended.

1. I agree to enter therapy with Connie Hornyak, LCSW. 2. I understand that I can leave therapy at any time.