NINA C. MILLER M.A., M.F.C.T.
(CELL) 909 229-9000
(F) 888 291-2457
LICENSE # MFC 12814
2990 Sierra Ave.
Norco, CA 92860
Welcome to Nina C. Miller and Associates. In an attempt to establish a smoothly running office system and a professional relationship with our clients, we have developed the following policies and procedures. We ask that you read and sign this information sheet in order to insure your understanding and willingness to abide by our established policies. Please do not hesitate to ask questions, and thank you in advance for your cooperation.
1. Sessions are 50 minutes in length. Overtime or phone consultation time is charged in 15 minute intervals. Payments are to be made at the time of your appointment. It is a good idea to pay at the beginning of each session so that you and your therapist are not rushed or distracted towards the end of your time.
2. In order to cancel or change an individual, marital, family or phone appointment, you must notify the office or your therapist at least 48 hours prior to the scheduled appointment. If your appointment is on a Monday, we need to be notified by Friday. If proper notice is not received, you are responsible for payment for the missed session. Phone therapy may be an option if circumstances prevent you from making an office visit. The same fee applies.
3. All group therapy sessions are charged to you regardless of attendance or notification of absence. This policy has been established as a way of fostering group cohesion and retaining your space in the group.
4. Insurance is the responsibility of each client. However, if you provide all the pertinent information required, we will make every attempt to file the insurance for you and/or expedite the process.
Fees are as follows:
Individual, Marital/Conjoint, Family Therapy, Phone Therapy $120.00 per session
Group Therapy (1 ½ to 2 hours) $50.00 per session
All communications between you and your therapist will be held in the strictest confidence unless you give written permission to release information. Exceptions to this confidentiality would be in those cases involving child abuse (sexual molestation or physical injury to a person under 18 years of age) and/or imminent danger to self or others. In these instances it is required by law that legal authorities be notified.
I have read, understood, and agree to the above policies of Nina C. Miller, M.A. and Associates.
Signature__________________________________Date____________________________
INTAKE FACE SHEET
The requested information becomes part of your file and is confidential.
Name: _____________________________________________________________________________
Home Address______________________________________________________________________
(Number and street)
______________________________________________________________________________
(City) (State) (Zip)
Home Phone _________________________ Cell Phone __________________________
Fax: _____________________________________
Email address: ____________________________________________________________
May we call you at home? Yes/No
Employed by ________________________________________________________________________
Business phone: ___________________________
Business Address_____________________________________________________________________
(Number and street)
_____________________________________________________________________________
(City) (State) (Zip)
Social Security Number______________________ Date of Birth _________________
Driver’s License Number: ______________________
Referred by ______________________________________________________________________________
In case of EMERGENCY contact: ________________________________________________________
(Name and Phone Number)
CONFIDENTIAL BACKGROUND INFORMATION
AGE:_________________ EDUCATION LEVEL:__________________________________
MARITAL STATUS:________________________________
SPOUSE OR PARTNER’S NAME:______________________________________________
PARTNER’S AGE:_______
PARTNER’S EDUCATIONAL LEVEL:__________________________________________
PARTNER’S OCCUPATION:_____________________
NUMBER OF CHILDREN:_______ NAMES AND AGES OF CHILDREN:
_____________________________________________________________________________
PREVIOUS COUNSELING:
_____________________________________________________________________________
(Name/names) (Dates)
HOSPITALIZATIONS:_________________________________________________________
(Reason-s) (Dates)
CURRENT CHRONIC CONDITIONS: ______________________________________________________________________________
FAMILY HISTORY OF MEDICAL PROBLEMS:
______________________________________________________________________________
FAMILY HISTORY OF PSYCHIATRIC PROBLEMS OR HOSPITALIZATION:
_____________________________________________________________________________
NUMBER OF BROTHERS AND SISTERS:_______ YOUR BIRTH ORDER: _______
PARENTS LIVING?: YES____ NO _____
DESCRIBE MOTHER:___________________________________________________________________
DESCRIBE FATHER:____________________________________________________________________
PERSONS CURRENTLY LIVING WITH YOU:__________________________________________________
Please state your current concerns and why you are coming into therapy.
______________________________________________________________________________