Intake Information for Andy Taylor, LCSW-R

Individual and Family Therapist

607-339-6106

www.andytaylorcounseling.com

andytaylor@stny.rr.com

Client Information

First Name: Enter here	Middle Initial: Enter here	Last: Enter here
Mobile Phone: Enter here	Work Phone: Enter here	Home Phone: Enter here
Street Address (City, State and Zip): Enter here
Email Address Enter here	Relationship Status:
Date of Birth: Enter here.
Occupation: Enter here	Employer: Enter here

Insurance and Billing Information

Person Responsible for Bill: Enter here	Date of Birth: Enter here
Address (if different): Enter here
Mobile Phone: Enter here	Work Phone: Enter here	Home Phone: Enter here
Primary Insurance: Enter here	Name and Date of Birth of Policy Holder: Enter here
Policy Number: Enter here	Group Number (if applicable): Enter here
Client’s relationship to the policy holder (self/spouse/child/other): Enter here.

Financial Responsibility

I understand that I am financially responsible for all charges whether or not paid by my insurance company and that full payment is expected at the time of each appointment. I authorize Andy Taylor, LCSW-R to release all information necessary to secure payment. I am responsible for all fees for the above-named client regardless of insurance coverage. Client Signature: Enter here Today’s Date: Click or tap to enter a date.

Medical Information

Serious Illness/Injuries: Enter here
Hospitalizations: Enter here
Operations: Enter here
Amount or use of cigarettes, alcohol and other drugs Enter here
Allergies (especially to medications): Enter here
Current Medications: Enter here
Previous contact with mental health professionals: Enter here

Family Information

Who is living at home at what is their relationship to you? Enter here
Do you have children? Yes/No/How many? Enter here
Please describe any mental health problems among relatives: Enter here

Other Information (if needed)

Enter here

Billing Information

Permission to Use the Billing and Administrative Services of MyClientsPlus MyClientsPlus is located in Pasco, Washington and specializes in providing confidential and HIPAA compliant billing and administrative services to mental health professionals in the United States. By signing below, I understand and give Andy Taylor, LCSW-R, permission to use the billing and administrative services of MyClientPlus Client Signature: Enter here Today’s Date: Click or tap to enter a date.

Release of Information

Release of information to your managed care, health insurance or employee assistance program I give permission to Andy Taylor, LCSW-R, to communicate as needed with my managed care, insurance company or Employee Assistance Program (EAP). This may include billing information, goals and treatment progress. My insurance company or EAP: Enter here Client Signature: Enter here Today’s Date: Click or tap to enter a date.

Informed Consent

INFORMED CONSENT TO TREATMENT Psychotherapy involves individuals, families, couples or groups talking with a mental health professional specifically trained to guide events toward positive, constructive change. Although there are no absolute guarantees, therapy can be beneficial for a variety of problems which without treatment may result in further impairment of functioning and decreased family cohesion and enjoyment. The benefits of treatment can include improved sense of well being, clearer view of choices and goals, improved relationship satisfaction and increased ability to be productive at home, school and work. At times during treatment, it may seem that the problem’s impact has worsened, but this is usually temporary and often necessary to the change process. The risks of treatment are minimal under the guidance of a properly qualified, ethical practitioner. You are encouraged to discuss any risks in your treatment with me. You may also want to explore alternatives to treatment available to you such as pastoral care, self-help groups and/or changes in your environment which may prove beneficial. I am a state-licensed, certified (R) social worker with over twenty years of work experience treating a variety of individuals, couples and families. I received my Master’s Degree in Social Work from Boston College. Therapy deals with important personal matters and the sharing of information (with some exceptions) is controlled by the client, NY State law, and professional ethics regarding confidentiality. Exceptions to confidentiality include: * Physical and sexual abuse of others which must be reported to the authorities under New York State Law. * Threats to harm self and/or others which the courts have determined should be reported both to the authorities and the intended victim. Other limits to confidentiality may exist in particular cases and should be discussed. Information may be released upon signing a Release of Information form or Managed Care Release. Please feel free to discuss with me any specifics regarding releasing information. Please feel free to discuss your questions, therapy procedures being used, and your fees with me at any time. Effective therapy involves a collaborative relationship between therapist and client(s) in a sustained search for solutions fitting your life circumstances. Due to managed care and different health insurance plans, fees for counseling can vary greatly. Your fee and/or co-pay will be discussed prior to starting counseling. CONSENT TO TREATMENT I have reviewed the materials attached regarding treatment and consent to treatment. I understand the fees and my responsibility for payment. Client Signature: Enter here Today’s Date: Click or tap to enter a date.