Client forms
Before …
… coming to your first session, please print and fill out the documents below.
Please print this page from a desktop or laptop computer, or a compatible tablet. The forms won't display or print properly from a small-screen device such as a mobile phone.
Agreement for Service/Informed Consent
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them.
Risks and Benefits of Therapy
Psychotherapy is a process in which you and I will discuss a myriad of issues, events, experiences and memories for the purpose of creating positive changes so that you can experience your life more fully.
Participating in therapy may result in a number of benefits to you, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. Such benefits may also require substantial effort on your part. There is no guarantee that therapy will yield any or all of the benefits listed above.
Confidentiality
All information about you and your therapy will be confidential unless:
-
you authorize the release of information with a signature (all members of treatment unit must sign the release);
-
there is a court order to release information;
-
you present a physical danger to yourself or others;
-
child or elder abuse is suspected.
To further protect your confidentiality I will not acknowledge you if we happen to see each other in public unless you acknowledge me first.
“No Secrets” Policy for Family and Couple Therapy
If you participate in family or couple therapy your therapist is permitted to share information obtained from an individual session if she feels this information is essential to effectively treat the family or couple.
Sessions and Appointments
A standard individual session runs for 50 minutes. The family and couple session runs for 80 minutes. In the event you must cancel or reschedule a session a minimum of 24 hours notice is required. In the event that unexpected circumstances prevent you from giving the 24 hours notice, the usual session fee will be charged.
Messages
My voicemail number is (707) 637-6020. Messages may be left for me any time of the day or night. I will return your calls as soon as possible. I may not be available for immediate emergency response. If you are in a life-threatening situation, call 911. To speak with a 24 hour crisis counselor call 1-800-784-2433.
Fees and Arrangements
The agreed upon fee is ____________. I reserve the right to periodically adjust the fee. You will be notified of any fee adjustment in advance. The fee is to be paid at the end of each session.
From time-to-time, we may engage in telephone contact for purposes other than scheduling sessions. You will be responsible for payment of the agreed upon fee for any telephone calls longer than 10 minutes.
Consent for Treatment
I hereby give consent to receive psychotherapeutic treatment from Kerstin Robbins, LMFT. I have read this document, understand its content and agree to these conditions.
Consent for the Treatment of Minors (when applicable)
I hereby give consent for my child(ren) named_________________________________________________________________________________
______________________________________________________________________________________________________________________ Signature Printed Name Date
Client History and Information
Basic Information
Today’s Date: _____________________________
Client Name:___________________________________________________________ Social Security Number: ________-______-________
Date of Birth: __________________________________________________________
Home Address: _____________________________________________________________________________________________________
Home Phone Number: ___________________________________________ May we leave a message? [ ] Yes [ ] No
Work Phone Number: ___________________________________________ May we leave a message? [ ] Yes [ ] No
Mobile Phone Number: __________________________________________ May we leave a message? [ ] Yes [ ] No
If the above patient is a minor, complete the following:
Name of Guardian: __________________________________________________________________________________________________
Address of Guardian: ________________________________________________________________________________________________
Guardian’s Home Phone Number: ___________________________________________ May we leave a message? [ ] Yes [ ] No
Guardian’s Work Phone Number: ___________________________________________ May we leave a message? [ ] Yes [ ] No
Guardian’s Mobile Phone Number: __________________________________________ May we leave a message? [ ] Yes [ ] No
Referral Source: ___________________________________________________________________________________________________
Emergency Contact Information
In case of an emergency, who should we contact?
Name: ______________________________________________________________________ Relationship: ________________________
Address: ________________________________________________________________________________________________________
Phone Number: ___________________________________________
History Information
Please describe the current complaint or problem as specifically as you can, in your own words.
How long have you experienced this problem, or when did you first notice it?
What stressors may have contributed to the current complaint or problem?
Check all words/phrases that describe what you are experiencing, and explain if possible.
[ ] Substance abuse/dependence
[ ] Addiction (internet, porn, shopping, exercise, gaming, gambling, etc.
[ ] Depression/Sad/Down feelings
[ ] High/Low energy level
[ ] Angry/Irritable
[ ] Loss of interest in activities
[ ] Difficulty enjoying things
[ ] Crying spells
[ ] Decreased motivation
[ ] Withdrawing from people/Isolation
[ ] Mood Swings
[ ] Black and white thinking/All or nothing thinking
[ ] Negative thinking
[ ] Change in weight or appetite
[ ] Change in sleeping pattern
[ ] Suicidal thoughts or plans/Thoughts of hurting yourself
[ ] Self-harm/Cutting/Burning yourself
[ ] Homicidal thoughts or plans/Thoughts of hurting others
[ ] Poor concentration/Difficulty focusing
[ ] Feelings of hopelessness/Worthlessness
[ ] Feelings of shame or guilt
[ ] Feelings of inadequacy/Low self-esteem
[ ] Anxious/Nervous/Tense feelings
[ ] Panic attacks
[ ] Racing or scrambled thoughts
[ ] Bad or unwanted thoughts
[ ] Flashbacks/Nightmares
[ ] Muscle tensions, aches, etc.
[ ] Hearing voices/Seeing things not there
[ ] Thoughts of running away
[ ] Paranoid thoughts/Thoughts that someone is watching you, out to get you or hurt you
[ ] Feelings of frustration
[ ] Feelings of being cheated
[ ] Perfectionism
[ ] Rituals of counting things, washing hands, checking locks, doors, stove, etc./Overly concerned about germs
[ ] Distorted body image (believe you are heavier or less attractive than others say you are)
[ ] Concerns about dieting
[ ] Feelings of loss of control over eating
[ ] Binge eating/Purging
[ ] Rules about eating/Compensating for eating
[ ] Excessive exercise
[ ] Indecisiveness about career
[ ] Job problems
[ ] Other:
Previous Treatment
Have you received or participated in previous counseling and/or therapy? [ ] Yes [ ] No
Additional Information:
What did you like/dislike about previous treatment?
What did you learn about yourself through previous counseling/treatment that may help you?
Have you had hospital stays for psychological concerns? [ ] Yes [ ] No
Additional Information:
Are you currently experiencing thoughts of harming either yourself or someone else? [ ] Yes [ ] No
Have you in the past experienced thoughts of harming either yourself or someone else? [ ] Yes [ ] No
Medical History
List any current or important past medications:
Medication & Dose Response to Medication
Other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during your lifetime:
Family History
Birth Location: ______________________________________________________________________________________________
Raised by: [ ] Mother [ ] Father [ ] Stepmother [ ] Stepfather [ ] Other: __________________________________________
Relationship with parent figures (good, fair, poor, close, distant, etc.):
Mother:
Father:
Step-parent:
Other:
List your siblings and describe your relationships with them:
Name Age Gender Nature of Relationship
Any history of neglect, and/or physical, verbal, emotional, spiritual, or sexual abuse?
Any family history of substance abuse, mental illness, suicide, or violence?
Any additional family information:
Social History
Describe your relationship with peers and/or friends:
How would you describe your social support network?
Describe your hobbies/interests:
Describe any cultural concerns:
Educational History
When attending school, were you:
[ ] in regular classes? [ ] home study? [ ] special classes? [ ] advanced classes? [ ] ever suspended? [ ] placed in an alternative school?
What is the highest educational level you have completed?
Give any additional important educational information (e.g., Did you like school? Have a learning disability?)
Occupational History
What is your current employment status?
[ ] Employed Full-Time [ ] Employed Part-time [ ] Unemployed [ ] Self-employed [ ] Student [ ] Other: ___________________________
Are you satisfied with your employment?
If not, why?
Marital History
Which best describes your marital status?
[ ] Married, Date: _________ [ ] Never Married [ ] Widowed, Date: _________ [ ] Separated, Date: _________ [ ] Divorced, Date: _________
If you are married, please briefly describe nature of your marital relationship:
If you are married, which best describes your marital satisfaction? [ ] Poor [ ] Fair [ ] Good [ ] Great
Please list any previous marriages/significant relationships including current:
Name Date Nature of Relationship
Do you have children? [ ] Yes [ ] No
If yes, complete the following:
First Name Age Gender Nature of Relationship
Substance Abuse History
Are you currently or have you ever struggled with substance abuse (alcohol, tobacco, marijuana, caffeine, or other)? [ ] Yes [ ] No
If you answered yes, please complete the following substance abuse history chart.
Substance Age of First Use Frequency of Use (Daily, Weekly, Monthly) Amount Used
Goals and Expectations
Summarize your goals for counseling/therapy:
What expectations do you have for counseling/therapy?
_____________________________________________________________ __________________________________________
Signature of Client or Guardian Date