"*" indicates required fields

The information requested in this form is for the use of the therapist only. If there are questions you would rather not answer, you may skip them.

Please note that all appointments cancelled with less than a 48 hour notice will be billed at the usual fee.

Today's Date

Type of Counseling

If you are completing the client intake form for couples counseling, please make sure that both you and your partner complete this intake form.

Individual

Couples

Full Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Home Phone

Work Phone

Date of Birth

Age

Place of birth

Email*

Please provide your anniversary or beginning of relationship

Please let us know if you want to receive information on couples tips for improving partnership, workshops and other information on healthy partnership

Yes

Current Occupation

Employer

Employer Address

Street Address Address Line 2 City State ZIP Code

Briefly describe your reasons for seeking Therapy:

Who referred you to me?

Please list 3 specific results you want to achieve in therapy:

(Use the "+" to add rows)

Please list any health problems for which you are currently receiving treatment or have a relevance to your physical and mental health.

Please list any medications you are now taking and the reason for taking them.

Have you been in Psychotherapy or counseling previously? If you have, please describe the circumstances and how your experience was, if you are currently in therapy please list the persons name, if needed do I have your permission to call them

Have you ever been treated for alcohol, drug addiction, eating disorders or any other addiction? If you have please describe circumstances and dates:

Are you currently in a recovery program?

Yes

Have you ever been hospitalized for mental health reasons? If you have please describe circumstances:

Relationship Status

Check all that apply

committed relationship

married

separated

divorced

widowed

single

If you don’t live alone, please list the members of your household, their age, and their relationship to you. If pets are considered part of your household, you may list them as well.

(Use the "+" to add rows)

Name

Age

Relationship

Please list the names and current ages of the members of your family of origin (those with whom you grew up). Include step family or others if you lived with them during childhood or adolescence.

(Use the "+" to add rows)

Name

Current Age

Relationship

Emergency Contact

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone

Work Phone

Current Problem Checklist

Check any of the following which are problems for you now.

Resolved Problem Checklist

Check any of the following any that used to be problems but seem to be resolved or at least are much better.

Guidelines and Consents

Rules and guidelines for therapy.

1. Cancellation Policy - If you do not show up for your scheduled appointment, and you have not notified us at least 48 hours in advance, you will be required to pay the full cost of the session as booked on the day of the appointment. If there is bad weather I will send a notice in the morning if the office is closed.

2. if you schedule an appt. for a couples session please do not show up individually without your partner without the therapists confirmed agreement. Couples who show up alone for scheduled couples sessions and have not spoken with their therapist about changing the appt. to an individual session will be asked to pay for the full couples session and will need to reschedule.

3. If you need to change or cancel an appt. you need to call or text 404-620-0533 and leave a message. All messages will be returned Mon.- Thurs. by the end of the day. If you call Friday through Sunday calls will be returned the following Monday. Please, do not use e-mail for scheduling.

4. Payment: Cash, check and creditcard are accepted for payment.

5. All clients are asked to have a final termination session when therapy has come to an end. When you decide to end therapy please let me know that's happening so we can schedule appropriately. Healthy closure is one of the most important things we do in human relationship.

6. If you are having a medical emergency and cannot get in touch with me personally please call 911 or the Georgia Crisis Access Line 1-800-715-4225

Consent to Correspond Electronically

While Allison Caffyn takes reasonable precautions to protect your confidential information, email, texting and social networking are not completely secure methods of communication.
Long distance consultation/coaching will be using videoconference, email, text and Whatsapp.
The purpose of email and other forms or electronic communication is to contact the client regarding scheduling appointments, reminding clients of their appointments, homework assignments, follow-up care or information regarding the client's business account. Electronic communication is not a way of communication new information regarding care or emergency treatment. This type of information will be exchanged in session.

I acknowledge that when I am choosing to engage in long distance consultation/coaching with Allie that we will be using videoconference, email, text, and Whatsapp. She has my permission to correspond with me via those same means of communication.

Authorization to Bill Credit Card

I understand that I am required to leave a credit card on file so that I can be charged for my sessions, and in case of missed appointments and late cancellations.

In order to avoid that charge, I must cancel my appointments at least 48 hours in advance by phone or email, at 404-312-8880 or alliecaffyn@gmail.com
All fees will be discussed prior to any billing.

Credit Card Number

Name as it appears on the Credit Card

Expiration Date

Security Code

Billing Zip Code

Insurance

Do you need a superbill for insurance?

Yes

What name is on the insurance card?

Consents*

I agree to the Rules and Guidelines for Therapy

I consent to correspond electronically

I authorize to bill my credit card

I have reviewed the HIPAA Guidelines

I have reviewed The Couples College Informed Consent Document

Client/Guarantor Signature*

If client is a minor (under the age of 18), form must be signed by parent or guardian.

Phone

This field is for validation purposes and should be left unchanged.

Featured Couples' Tip

Emergency Contact

Guidelines and Consents

Rules and guidelines for therapy.

Consent to Correspond Electronically

Authorization to Bill Credit Card

Insurance

HIPAA

No Surprises Act - Your Rights as a client of The Couples College

Informed Consent

Notice

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Allie’s Client Intake Form

Emergency Contact

Guidelines and Consents

Rules and guidelines for therapy.

Consent to Correspond Electronically

Authorization to Bill Credit Card

Insurance

HIPAA

No Surprises Act - Your Rights as a client of The Couples College

Informed Consent