Feeling Good Therapy - New Patient Intake Form

Full Name *

First Name Last Name

Phone Number *

Area Code Phone Number

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail *

Age

Birth Date *

Month Day Year

Marital Status

Employer

Occupation

Spouse's Name

Spouse's Occupation

Spouse's Employer

Number of Children

Children's genders and ages

Emergency Contact *

Emergency Contact Phone Number *

Primary Care Physician *

Primary Care Physician's Phone Number *

How were you referred to us?

How I plan to pay for therapy (Note: We are out of network with all insurance carriers.) *

I would like to pay with credit card

Please add your mobile number below so we can text you a payment request via IVY, which is the secure app we use for online payments.

Area Code Phone Number

Are you experiencing any of the following? (Please check all that apply) *

List all other major illnesses or hospitalizations:

What medications or drugs are you taking?

Have you been treated for any mental health conditions in the last year?

Yes No

List any other health problems, no matter how insignificant it may be:

Purpose of this appointment: *

Have you ever had the same or a similar problem?

Yes No

If yes, please describe:

Please check all that apply *

If you checked any of the options above, please detail below:

What are your hobbies?

Father

Living Deceased

Father's current age or age at time of death and cause of death: *

Mother

Living Deceased

Mother's current age or age at time of death and cause of death: *

Do you have any family members who suffer from the condition that you do? If so, please list: *

Do any of your family members suffer from these? (Please check all that apply) *

Patient's Name

If patient is a minor, parent/guardian's name

Clinician Name

Enter the message as it's shown *

Sign Here (use your finger or mouse) *

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Consent to Use and Disclose Your Health Information

This form is an agreement between you, and Feeling Good Wellness Center (FGWC). When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name here.

When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls “protected health information” or (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, or to help provide other treatment to you. By signing this form, you are agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explains what your rights are and how we can use and share your information.

In order to optimize your care, from time to time we seek consultations with other licensed mental health professionals who are in the role of an expert in the matter that we seek consultation. When we do this, we eliminate all demographic and identifiable factors in order to maintain confidentiality and would limit the consultation to the specific issue we are consulting about.

If you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do agree, we promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing. We will then stop using or sharing your PHI, but we may already have used or shared some of it, and we cannot change that.

If you do not sign this form agreeing to our privacy practices, we cannot treat you.

Consent to Use and Disclose Your Health Information This form is an agreement between you, and Feeling Good Therapy and Training Center (FGTTC). When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name here.When we examine, test, diagnose, treat, or refer you, we will be collecting what the law calls “protected health information” or (PHI) about you. We need to use this information in our office to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others to arrange payment for your treatment, or to help provide other treatment to you. By signing this form, you are agreeing to let us use your PHI and to send it to others for the purposes described above. Your signature below acknowledges that you have read or heard our notice of privacy practices, which explains what your rights are and how we can use and share your information.In order to optimize your care, from time to time we seek consultations with other licensed mental health professionals who are in the role of an expert in the matter that we seek consultation. When we do this, we eliminate all demographic and identifiable factors in order to maintain confidentiality and would limit the consultation to the specific issue we are consulting about. If you are concerned about your PHI, you have the right to ask us not to use or share some of it for treatment, payment, or administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to accept these limitations. However, if we do agree, we promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing. We will then stop using or sharing your PHI, but we may already have used or shared some of it, and we cannot change that.If you do not sign this form agreeing to our privacy practices, we cannot treat you.

I AGREE

** Sign Here to confirm that you have read and understood the terms and conditions listed above in the section titled, "Consent to Use and Disclose Your Health Information" — (use your finger or mouse) *

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What You Should Know about Confidentiality in Therapy

At Feeling Good Wellness Center (FGWC) we treat you with great care. Our professional ethics (that is, our profession’s rules about values and moral matters) and the laws of this state prevent us from telling anyone else what you tell us unless you give us written permission.

These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the “confidentiality” of therapy. But we cannot promise that everything you tell us will never be revealed to someone else. There are sometimes when the law requires us to tell things to others. There are also some other limits on our confidentiality.

We need to discuss these because we want you to understand clearly what we can and cannot keep confidential. So please read these pages carefully. Please ask to discuss or ask any questions you might have regarding this matter.

A: When you or other persons are in physical and/or psychological danger, the law requires us to tell others about it. Specifically:

If we come to believe that you are threatening serious harm to another person, we are required to try to protect that person. We may have to tell the person and the police, or perhaps try to have you put in a hospital.
If you seriously threaten or act in a way that is very likely to harm yourself, we may have to seek a hospital for you or to call on your family members or others who can help protect you. If such a situation does come up, we will fully discuss the situation with you before we do anything, unless there is a very strong reason not to.
In an emergency where your life or health is in danger, and we cannot get your consent, we may give another professional some information to protect your life. We will try to get your permission first, and we will discuss this with you as soon as possible afterward.
If we believe or suspect that you or someone you tell us are/is abusing a child, an elderly person, or a disabled person we must file a report with a state agency. To “abuse” means to neglect, hurt, or sexually molest another person. The Child Abuse and Neglect Reporting Act defines sexual abuse as sexual assault or sexual exploitation. California law (AB 1775) defines sexual exploitation to include a person who knowingly downloads, streams, accesses through any electronic or digital media, or exchanges, a film, photograph, videotape, video recording, negative, or slide in which a child is engaged in an act of obscene sexual conduct. If we suspect a child is being harmed through sexual abuse, we must file a report with the appropriate agency. We do not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. If this might be your situation, we should discuss the legal aspects in detail before you tell us anything about these topics. You may also want to talk to your lawyer.

B: In any of the following situations, we would reveal only the information that is needed to protect you or the other person. We would not tell everything you have told us.

1. In general, if you become involved in a court case or proceeding, you can prevent us from testifying in court about what you have told us. This is called “privilege,” and it is your choice to prevent us from testifying or to allow us to do so. However, there are some situations where a judge or court may require us to testify:

a) In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt.

b) In cases where your emotional or mental condition is important information for a court’s decision.

c) During a malpractice case or an investigation of us or another therapist by a professional group.

In a civil commitment hearing to decide if you will be admitted to or continued in a psychiatric hospital.
When you are seeing us for court-ordered evaluations or treatment. In this case, we need to discuss confidentiality fully, because you don’t have to tell us what you don’t want the court to find out through our report.
If you were sent to us for an evaluation by worker’s compensation or Social Security disability, we will be sending our report to a representative of that agency and it can contain anything that you tell us.

What You Should Know about Confidentiality in TherapyAt Feeling Good Therapy and Training Center (FGTTC) we treat you with great care. Our professional ethics (that is, our profession’s rules about values and moral matters) and the laws of this state prevent us from telling anyone else what you tell us unless you give us written permission.These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the “confidentiality” of therapy. But we cannot promise that everything you tell us will never be revealed to someone else. There are sometimes when the law requires us to tell things to others. There are also some other limits on our confidentiality.We need to discuss these because we want you to understand clearly what we can and cannot keep confidential. So please read these pages carefully. Please ask to discuss or ask any questions you might have regarding this matter. A: When you or other persons are in physical and/or psychological danger, the law requires us to tell others about it. Specifically:If we come to believe that you are threatening serious harm to another person, we are required to try to protect that person. We may have to tell the person and the police, or perhaps try to have you put in a hospital.If you seriously threaten or act in a way that is very likely to harm yourself, we may have to seek a hospital for you or to call on your family members or others who can help protect you. If such a situation does come up, we will fully discuss the situation with you before we do anything, unless there is a very strong reason not to.In an emergency where your life or health is in danger, and we cannot get your consent, we may give another professional some information to protect your life. We will try to get your permission first, and we will discuss this with you as soon as possible afterward.If we believe or suspect that you or someone you tell us are/is abusing a child, an elderly person, or a disabled person we must file a report with a state agency. To “abuse” means to neglect, hurt, or sexually molest another person. The Child Abuse and Neglect Reporting Act defines sexual abuse as sexual assault or sexual exploitation. California law (AB 1775) defines sexual exploitation to include a person who knowingly downloads, streams, accesses through any electronic or digital media, or exchanges, a film, photograph, videotape, video recording, negative, or slide in which a child is engaged in an act of obscene sexual conduct. If we suspect a child is being harmed through sexual abuse, we must file a report with the appropriate agency. We do not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. If this might be your situation, we should discuss the legal aspects in detail before you tell us anything about these topics. You may also want to talk to your lawyer. B: In any of the following situations, we would reveal only the information that is needed to protect you or the other person. We would not tell everything you have told us. 1. In general, if you become involved in a court case or proceeding, you can prevent us from testifying in court about what you have told us. This is called “privilege,” and it is your choice to prevent us from testifying or to allow us to do so. However, there are some situations where a judge or court may require us to testify:a) In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt.b) In cases where your emotional or mental condition is important information for a court’s decision.c) During a malpractice case or an investigation of us or another therapist by a professional group.In a civil commitment hearing to decide if you will be admitted to or continued in a psychiatric hospital.When you are seeing us for court-ordered evaluations or treatment. In this case, we need to discuss confidentiality fully, because you don’t have to tell us what you don’t want the court to find out through our report.If you were sent to us for an evaluation by worker’s compensation or Social Security disability, we will be sending our report to a representative of that agency and it can contain anything that you tell us.

I AGREE

** Sign here to show that you (and the minor, if applicable ) each have read, understood, and agree to abide by the points presented above in the section titled, "Confidentiality" — (use your finger or mouse to sign) *

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Consent to Treatment

I do hereby seek and consent to take part in treatments at the Feeling Good Wellness Center (FGWC). I understand that developing a treatment plan with my treating psychologist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that there can not be a guarantee on the outcome of my treatment given the multivariable nature of psychotherapy. However, I understand every effort is put forth in helping me overcome my symptoms during the course of my treatment.

Commitment to Cultural Humility, Anti-Racism, and Diversity.

I understand Dr. Dashtban makes humble best efforts to take an anti-oppressive stance in her teaching and treatment approach and requests feedback when patients see her fall short of this effort.

Given the nature of the outpatient setting in private practice, and the fact that all psychotherapy sessions are offered via telehealth online, no crisis management or emergency care is available at FGWC. By signing this form, I demonstrate my understanding and agreement that I should call 911 or go to the nearest hospital should I experience a mental health crisis or an emergency. I also acknowledge that Dr. Dashtban or FGWC is not available to provide me with mental health services outside of my scheduled appointments.

I am aware that I may stop my treatment at FGWC at any time. The only thing I will still be responsible for is paying for the services I have already contracted for. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 48 hours (2 business days) before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment.

I am aware that an agent of my insurance company or other third-party payers may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the psychologist/therapist may stop my treatment.

I am aware that as part of quality assurance, my psychologist or therapist may share some aspects of my case and/or my treatment with her/his colleagues at FGWC or within the community of psychologists/therapists she/he works with. I understand that the sole purpose of such case consultation is to improve the care that I receive and my treating psychologist/therapist will disclose no personal or identifying information to her/his colleagues within FGWC or those outside of the center.

I understand that my services at FGWC do not extend to child custody cases. We do not and will not make any child custody recommendations when treating a minor who is involved in a custody conflict. Parents and guardians who agree to engage our services for their minor contract that as the treating psychologist/therapist, we will not be called to testify or have records subpoenaed for any and all matters relating to custody conflicts. If there is any initial report made to Child Protective Services, parents and guardians agree to contract for release for the psychologist/therapist to have follow-up contact with Child Protective Services. Likewise, we do not and will not agree to make any psychological evaluations, provide clinical services, or serve in any other ways for the purposes of fulfilling a court-ordered, mandated, or otherwise legally required clinical task.

Consent to TreatmentI do hereby seek and consent to take part in treatments at the Feeling Good Therapy and Training Center (FGTTC). I understand that developing a treatment plan with my treating psychologist or therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by my provider at Feeling Good Therapy and Training Center. I am aware that I may stop my treatment at FGTTC at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.) I know that I must call to cancel an appointment at least 48 hours (2 business days) before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment. I am aware that an agent of my insurance company or other third-party payers may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the psychologist/therapist may stop my treatment.I am aware that as part of quality assurance, my psychologist or therapist may share some aspects of my case and/or my treatment with her/his colleagues at FGTTC or within the community of psychologists/therapists she/he works with. I understand that the sole purpose of such case consultation is to improve the care that I receive and my treating psychologist/therapist will disclose no personal or identifying information to her/his colleagues within FGTTC or those outside of the center. I understand that my services at FGTTC do not extend to child custody cases. We do not and will not make any child custody recommendations when treating a minor who is involved in a custody conflict. Parents and guardians who agree to engage our services for their minor contract that as the treating psychologist/therapist, we will not be called to testify or have records subpoenaed for any and all matters relating to custody conflicts. If there is any initial report made to Child Protective Services, parents and guardians agree to contract for release for the psychologist/therapist to have follow-up contact with Child Protective Services. Likewise, we do not and will not agree to make any psychological evaluations, provide clinical services, or serve in any other ways for the purposes of fulfilling a court-ordered, mandated, or otherwise legally required clinical task.

I AGREE

** My signature below shows that I understand and agree with all of the statements in the section titled "Consent to Treatment." — (use your finger or mouse to sign) *

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Financial Agreement

PLEASE READ THE FOLLOWING AGREEMENT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE BRING THEM UP PRIOR TO YOUR FIRST SESSION BY PHONE OR EMAIL. YOU ARE REQUIRED TO SIGN AND SUBMIT THIS FORM PRIOR TO BECOMING A PATIENT AT FEELING GOOD WELLNESS CENTER. BY SIGNING THIS FORM, YOU ARE AGREEING TO THE TERMS OF FINANCIAL RESPONSIBILITY ASKED OF YOU IN ORDER TO BECOME A PATIENT OF FEELING GOOD WELLNESS CENTER.

Services at Feeling Good Wellness Center (FGWC) include but are not limited to psychotherapy, psychological testing, and evaluations, consultation with others about your care, reading supporting documents about your care and preparing documents for your care.

No services will be done without your prior agreement.

Our clinicians are considered out of network providers with all commercial insurance companies. This means you are responsible for making payments for the services you receive prior to the time of service. You will receive a payment request through text or email which will ask you to provide a payment or a credit card number. We use credible and secure payment platforms and do our part in keeping all financial information safe.

If you are interested in submitting claims to your insurance carrier you are welcome to ask your clinician for a superbill, which will be provided to you at no additional charge.

FGWC is not responsible for the transactions between you and your insurance carrier, nor does it guarantee payments from your insurance carrier.

All appointment cancellations or changes must be made within 48 hours (2 work days) prior to the appointed time. All late cancellations and appointment no-shows will be charged at the full rate. All cancellation notices must be made either by a phone call to the office (831-621-1150) or by email to info@feelinggoodtherapy.com

Should you choose to discontinue services before reaching your therapy goals, you are responsible for clearing payments for all the services you have received up to that point, there are no refunds for services rendered. You are not responsible for paying for any future appointments, should you cancel them within 48 hours (2 work days) prior to the appointed time.

In order to become a patient at FGWC, you are required to provide a valid credit card on file. Your credit card on file will only be charged for late cancellations or no-shows, as well as incidental charges that have not been cleared prior to or at the time of service. We keep your financial information confidential and use HIPPA regulations in the safe keep of your information. Please be prepared to provide a valid credit card to your clinician on the day of your first appointment.

Typically a standard therapy session is 50 minutes long. However, at FGWC we frequently tailor your therapy sessions as a double session which lasts 100 minutes or (1 hour and 40 minutes). This is to ensure a clinically beneficial and productive session in which there is ample time for treatment. The fee for double sessions is charged at our currently established hourly rates ($250 for psychotherapy, $300 for intake) times the number of hours per session. A typical intake meeting is, therefore, $600 and a typical weekly psychotherapy session is $500.

At FGWC we offer our clinical services within a course of treatment of 5 weeks at a time. Payment for each 5-week course of treatment is due on the first day of the treatments. Any credits left unused for the 5-week course of treatments will be kept for 90 days during which you'd have to either request a refund or use the credit. All unused credits that are passed 90 days are forfeited and no refunds will be available for them.

Financial AgreementPLEASE READ THE FOLLOWING AGREEMENT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE BRING THEM UP PRIOR TO YOUR FIRST SESSION BY PHONE OR EMAIL. YOU ARE REQUIRED TO SIGN AND SUBMIT THIS FORM PRIOR TO BECOMING A PATIENT AT FEELING GOOD THERAPY AND TRAINING CENTER. BY SIGNING THIS FORM, YOU ARE AGREEING TO THE TERMS OF FINANCIAL RESPONSIBILITY ASKED OF YOU IN ORDER TO BECOME A PATIENT OF FEELING GOOD THERAPY AND TRAINING CENTER.Services at Feeling Good Therapy and Trainig Center (FGTTC) include but are not limited to psychotherapy, psychological testing, and evaluations, consultation with others about your care, reading supporting documents about your care and preparing documents for your care.No services will be done without your prior agreement.Our clinicians are considered out of network providers with all commercial insurance companies. This means you are responsible for making payments for the services you receive either prior to, or at the time of service, directly to your treating clinician. If you are interested in submitting claims to your insurance carrier you are welcome to ask your clinician for a superbill, which will be provided to you at no additional charge.FGTTC is not responsible for the transactions between you and your insurance carrier, nor does it guarantee payments from your insurance carrier. All appointment cancellations or changes must be made within 48 hours (2 work days) prior to the appointed time. All late cancellations and appointment no-shows will be charged at the full rate. All cancellation notices must be made either by a phone call to the office (510-400-6160) or by email to info@feelinggoodtherapy.comShould you choose to discontinue services before reaching your therapy goals, you are responsible for clearing payments for all the services you have received up to that point, there are no refunds for services rendered. You are not responsible for paying for any future appointments, should you cancel them within 48 hours (2 work days) prior to the appointed time.In order to become a patient at FGTTC, you are required to provide a valid credit card on file. Your credit card on file will be charged for late cancellations or no-shows, as well as incidental charges that have not been cleared prior to or at the time of service. We keep your financial information confidential and use HIPPA regulations in the safe keep of your information. Please be prepared to provide a valid credit card to your clinician on the day of your first appointment. Most therapy sessions are at the standard length of 50 minutes. However, frequently it becomes clinically beneficial to sign up for a double session, which lasts 100 minutes (1 hour and 40 minutes). All double sessions will be offered with your prior agreement. The fee for double sessions is charged at the same hourly rate times the number of sessions.

I AGREE

** Your signature below means you have carefully read, understood and agree with the statements disclosed in the section "Financial Agreement." — (use your finger or mouse) *

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New Patient Intake Form

Personal Information

Financial Information

Personal History

History of the Present Problem

Social History

Family History

Signature and Submission

Consent to Use and Disclose Health Information

Confidentiality

Consent to Treatment

Financial Agreement