Client Intake Packet

Your Name

Your Email

Address

City

Home Phone

Work Phone

Cell Phone

DOB

Age

May we...

Leave messages at the above phone numbers?
YesNo

Send appointment reminders via text message to the above cell number?
YesNo

Contact you via email if we cannot reach you by phone?
YesNo

Email you payment receipts for services?
YesNo

Name and Number of Emergency Contact Person

How did you hear about the Counseling/Coaching Services of Aubrey & Hugh Consulting LLC?

Briefly describe the issues/problems that led you to seek counseling

What goals would you like to achieve with counseling?

POLICIES AND CONSENT TO CONSULTATION SERVICES

FINANCIAL POLICY Full payment is due at time of service (unless prior arrangements have been made). Please feel free to ask if you have any questions about our financial policy. Understanding our financial policy is important to our relationship. Aubrey & Hugh does not take or accept any Insurance policy for payment. You are responsible for the timely payment of your Account. Uncollected balances may be turned over for collection or reported to the state’s attorney’s office. Payments can be made via PayPal using link: paypal.me/DrWAR or by using the email aubreyandhugh@gmail.com

CANCELLATION POLICY Please help us to serve you and others better by keeping your scheduled appointments. If you need to cancel or reschedule, please give us as much notice as possible so we can offer that time to someone else. Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal consultation session. This will be billed to you. We may require prepayment in order to schedule a subsequent appointment.

CONFIDENTIALITY Federal and State laws protect your confidentiality (See 42 U.S.C. 290dd-3 and 290ee-3 for Federal laws and 42 CFR Part 2, section 33.13 of the Mental Hygiene Law-NY State). Your counselor/coach will not share information with any person outside of Aubrey & Hugh Consulting LLC, without your written permission.

Exceptions to Confidentiality: Federal regulations do not protect from disclosure of information related to a client’s involvement in a crime against property or personnel. We are required under State law to report suspected abuse of a child, elderly person, or individual with a disability. We may share limited information in the event of a medical emergency or in the event of a specialized court order signed by a judge. Your counselor/coach has the option of breeching confidentiality if you report a specific plan or intent to cause serious bodily harm to an identifiable person.

CONSENT TO LIFE STRATEGIZING SERVICES I am voluntarily seeking counseling/coaching services from Aubrey & Hugh Consulting LLC,. I understand that I have rights and responsibilities regarding my participation in my life management work, including the right to discontinue. I am strongly encouraged to discuss my coaching plan and status in sessions with my counselor/coach. Counselors will also discuss alternatives, procedures, qualifications, and drawbacks to any particular counseling approach. With my signature below, I acknowledge that I have read, understand, and agree to all of the above. I also acknowledge that I have been informed of HIPPA/Privacy Practices implemented here at Aubrey & Hugh Consulting.

Individual/group counseling/coaching sessions are intended to be 45-55 minutes in length, at price rate that begins at $55.00 per session.

Please note: We do not provide emergency services. In true crisis call 911.

checking this box to affix electronic signature, I acknowledge that I understand the above information and consent to LIFE STRATEGIZING services at Aubrey & Hugh Consulting LLC

Parent’s/Guardian’s Printed Name

CHECKLIST OF CONCERNS

Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.”

Abuse—physical, sexual, emotional, neglect of children or elderly persons, cruelty to animalsAggression, violenceAlcohol useAnger, hostility, arguing,irritabilityAnxiety, nervousnessAttention, concentration, distractibilityCareer concerns, goals, and choicesChildhood issues (your own childhood)CodependenceConfusionCompulsionsCustody of childrenDecision making, indecision, mixed feelings, putting off decisionsDelusions (false ideas)DependenceDepression, low mood, sadness, cryingDivorce, separationDrug use—prescription medications, over-the-counter medications, street drugsEating problems—overeating, under eating, appetite, vomiting see also “Weight and diet issues”)EmptinessFailureFatigue, tiredness, low energyFears, phobiasFinancial or money troubles, debt, impulsive spending, low incomeFriendshipsGamblingGrieving, mourning, deaths, losses, divorceGuiltHeadaches, other kinds of painsHealth, illness, medicalconcerns, physical problemsHousework/chores—quality,schedules, sharing dutiesInferiority feelingsInterpersonal conflictsImpulsiveness, loss of control, outburstsIrresponsibilityJudgment problems, risk takingLegal matters, charges, suitsLonelinessMarital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointmentsMemory problemsMenstrual problems, PMS, menopauseMood swingsMotivation, lazinessNervousness, tensionObsessions, compulsions (thoughts or actions that repeat themselves)Oversensitivity to rejectionPanic or anxiety attacksParenting, child management, single parenthoodPerfectionismPessimismProcrastination, work inhibitions, lazinessRelationship problems (with friends, with relatives, or at work)School problems (see also “Career concerns”)Self-centerednessSelf-esteemSelf-neglect, poor self-careSexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”)Shyness, oversensitivity to criticismSleep problems—too much, too little, insomnia, nightmaresSmoking and tobacco useSpiritual, religious, moral, ethical issuesStress, relaxation, stress management, stress disorders, tensionSuspiciousnessSuicidal thoughtsTemper problems, self-control, low frustration toleranceThought disorganization and confusionThreats, violenceWeight and diet issuesWithdrawal, isolatingWork problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambition frustrations

Any other concerns or issues:

Which of the above concerns do you most want help with?

Psychosocial History

Treatment History

Have you ever participated in counseling, psychotherapy, psychiatric/mental health treatment, or substance abuse treatment? Other services? If so, please complete the following information to the best of your ability:
Date(s) | Provider | Purpose/Focus of Treatment | Outcome

Trauma History

Did you experience any physical, sexual, or emotional/psychological abuse or neglect during childhood or as an adult? If so, please describe:

Have you had any experiences you’d consider to be traumatic (e.g., threat of serious harm/injury, natural disaster, victim of a crime, traumatic losses/deaths, etc.)? If so, please describe:

Has anyone in your family ever been diagnosed or treated for a mental health disorder or for an alcohol- or drug-related problem? Has anyone had these problems but not been treated? If either apply, please indicate below: Family Member | Problem/Disorder | Describe Treatment (if any)

Medical Conditions & History

Do you have any current or recent medical/physical concerns?
yesno
Describe:

Do you have a primary care physician?
yesno
Name of Physician/Practice:

Please describe any history of surgeries, significant medical procedures, or ER visits, or major illnesses (including dates if possible):

Medications (including dosages, prescribing physician, and purpose of medication):

Allergies:

Substance Use

Please enter the following information for any substances including alcohol, tobacco, and drugs that you currently use or have used in the past:

Substance
Past Use? yesno
Current Use? yesno
How often/how much in past year?

Family History

Were you adopted? yesno

Who lived with you growing up?

Did you have brothers or sisters? yesno

If so, list their names and ages:

Did/do you have stepparents?yesno
How would you describe your family growing up?
What was your parents’ relationship with each other like?
What was your relationship with your mother like growing up?
What is your relationship with her like now (if living)?
What was your relationship with your father like growing up?
What is your relationship with him like now (if living)?

Did you experience any physical, emotional, or sexual abuse or neglect as a child or as an adult?
yesno
Describe:

What is your relationship status (check all that apply)?
SingleMarriedDatingCo-habitatingDivorcedSeparatedOther
If you chose "other", describe:

Do you have children? yesno

Names and ages:

Social, Spiritual, & Developmental History

Where were you born?
Where did you live growing up?
Were there any complications with your birth?
Were there any developmental delays growing up
What were your friendships like growing up?
Describe your friendships now:
Who do you turn to for support?
How many serious relationships have you been in your life?
Describe your history of romantic relationships:
Are you in a relationship now?yesno
If so, for how long?
Describe your relationship with your significant other
Describe your sexual orientation: HeterosexualHomosexualBisexualPansexualQuestioningAsexualOther If other describe:
Describe your religious or spiritual beliefs:
Describe any social groups or institutions you are involved in (e.g., clubs, associations, congregations):
What do you do in your spare time?

Educational and Vocational History

What was school like for you growing up?
What is the highest level of education/highest grade you completed?
If you went to college or grade school, what degrees or certifications did you earn?
Describe your employment history:
Are you working now?yesno
What is your occupation?
Are you satisfied with your Annual income?
Describe any vocational/occupational goals you may have for the future

Legal History

Have you ever been arrested? If so, when and what charge(s)?
Describe any current legal concerns:

Other Information

What are your strengths?
Anything else you want us to know?

yesno
If yes describe: