Intake Form for Psychotherapy

NINA C. MILLER M.A., M.F.C.T.
(CELL) 909 229-9000
(F) 888 291-2457
LICENSE # MFC 12814

2990 Sierra Ave.                                                                                                        11801 Pierce St. Ste 200
Norco, CA  92860                                                                                                      Riverside, CA 92505

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             $110.00 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.

______________________________________________________________________________

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