New Client Info

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Please fill out this form before your first appointment .

Please fill out this form completely. Please note your signature is required at the bottom of the form.

Name
First
Address
Street Address Address Line 2 City State ZIP Code
Best telephone number to reach you
- Home
- Work
- Cellular
Home Phone
Work Phone
Cellular Phone
Email

Please be advised that I can't guarantee that your email or text communication is private. Please limit your email and text to scheduling concerns.
I am authorized to leave you messages on:
- home
- work
- cell
- email
- other
Other
Date of Birth
Date Format: MM slash DD slash YYYY
Credit Card Number
Sessions will be charged to your credit card unless other arrangements are made. If we have trouble with the credit card information an administrative person from my office will contact you by phone. My fee is $175.00 per session.
Expiration Date
Verification code on back of card
Martial Status
- Married
- Single
- Widowed
- Divorced
- Seperated
- Domestic Partner
How did you find me?
Who referred you?
Student Status
- Full Time
- Part Time
Institution
Who should be contacted in the event of an emergency?
Name
First Last
Relationship to you
Address
Street Address Address Line 2 City State ZIP Code
Best Phone Number
Please list psychiatric medications you have taken in the past and describe your response:
List all medications you are currently taking. Include supplements and over the counter medications. Please include dose and frequency of each medication.
List any drug or other allergies you have:
Health History Questions - Optional
The following questions are about you and your health history. You are not obligated to answer these questions though doing so will give me more time to focus on what has brought you into treatment.
What brings you to therapy?
Have you been in therapy before?
- Yes
- No
If yes, with whom?
Number
Alcohol use?
- Yes
- No
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Number of drinks per week
Do you exercise?
- Yes
- No
Type and frequency?
Average hours of sleep per night?
Do you have trouble falling asleep?
- Yes
- No
Do you have trouble staying asleep?
- Yes
- No
List names, ages and relations of those you live with and names and ages of any children you may have:
Who raised you?
List siblings and their ages:
Were your parents divorced?
- Yes
- No
If yes, how old were you?
Did one of your parents or siblings die during your childhood?
- Yes
- No
If yes, how old were you?
How far did you go in school?
- High School
- Some College/Technical School
- College
- Graduate School
- Specialized Training
Any strong religious affiliation or spiritual practices?
- Yes
- No
If yes, please describe:
Have any of your blood relatives experienced any of the following illnesses listed below? Please indicate which ones and which relative had the illness (mother, father, brother, etc.)
Depression, Bipolar disorder/manic-depression, Alcoholism/drug abuse, Sever trauma, ADHD/learning disorders, Attempted or completed suicide, Anorexia/bulimia, Sever obesity, Anxiety/nerves, Epilepsy/seizures, High blood pressure, Diabetes, Cancer, Schizophrenia, Alzheimer's or Parkinsons Disease, Psychiatric hospitalization
CLIENT DISCLOSURE STATEMENT (INFORMATION AND CONSENT)
I am pleased you have selected me as your counselor. This document is designed to inform you of my background and to ensure that you understand our professional relationship.
Degrees/Licenses/Certificates
I hold a Bachelor of Arts in Clinical Psychology from UNC-Chapel Hill. I attended NCCU on a scholarship and graduated Summa Cum Laude with a Master of Arts in Clinical Psychology in 1988.1 have been in private practice since 1988.1am licensed as a Professional Counselor (license #2793, issued July 1, 1997), as well as having certification as a Health Services Provider (issued December 1, 1994). Both licenses involve successfully completing a body of required coursework, passing nationally standardized licensing exams in addition to clinical internships, and hundreds of hours of supervised clinical practice. Following licensure I have pursued ongoing training in the area of psychodynamic psychotherapy.
Counseling Services Offered/Theoretical Approaches
I offer individual psychodynamic psychotherapy for adults and older adolescents. I treat diagnoses that include: personality disorders, adjustment, anxiety, and depressive disorders. I see clients for weekly sessions from one to three times a week depending on the nature and intensity of the work. My approach could best be described as psychodynamic/psychoanalytic. This approach has its theoretical roots in the early discoveries of Dr. Sigmund Freud about unconscious conflicts. These theories have undergone changes and advancements that span over 100 years. Psychodynamic psychotherapy focuses on both the conscious and unconscious factors that act to keep a person stuck in painful ways of relating to others and to himself/herself. Current psychodynamic theories emphasize the importance of self-esteem, relationship trauma, and empathy. The process of psychodynamic therapy involves uncovering and working through this painful forgotten material. Through the client's expressed current concerns and difficulties there emerge patterns and links to this unconscious material. Insight and healing are set into motion through a collaborative, careful and empathic examination of the patient's thoughts and feelings. As awareness is gained, the client is freed psychologically to make choices in work and relationships that alleviate suffering and bring greater joy and satisfaction.
Business Policies
After an evaluation period you can expect me to hold a regularly scheduled time(s) for you each week that we agree upon. My fee is $175.00 per session. I ask that you give me 24 hours notice if you must cancel. I charge the full fee for missed sessions with the exception of illness or unavoidable emergencies. Your monthly statement has the appropriate information for filing insurance. Be aware that there is great variability in insurance coverage. It will include a diagnosis which becomes part of your medical record. You are personally responsible for any fees incurred. Any information regarding your treatment is confidential and will not be released without your permission. Legal mandates give two exceptions to this policy; (1) if a client is believed to be harmful to himself/herself or others, or (2) situations where there is suspected child or elder abuse, or (3) by court order. I am legally bound to break confidentiality and report such instances.
If you believe you have been treated unethically or unfairly by me you may contact the North Carolina Board of Licensed Professional Counselors at PO. Box 7369, Garner, NC. 27529, (919) 667-0820 for clarification of client's rights as I've explained them or to lodge a complaint.
Signature*
Comments
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If you prefer to download a printable PDF version of this form to mail or bring by the office click here.

New Client Info

New Client Info

Who should be contacted in the event of an emergency?

Health History Questions - Optional

CLIENT DISCLOSURE STATEMENT (INFORMATION AND CONSENT)

Degrees/Licenses/Certificates

Counseling Services Offered/Theoretical Approaches

Business Policies