1758B Century Blvd NE Atlanta, GA 30345
info@thecouplescollege.com
404-620-0533
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Elena’s Client Intake Form
Elena’s Client Intake Form
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
MM slash DD slash YYYY
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Cell Phone
Home Phone
Work Phone
Date of Birth
Month
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Day
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Age
Place of birth
Email
*
Please provide your anniversary or beginning of relationship
Month
1
2
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4
5
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7
8
9
10
11
12
Day
1
2
3
4
5
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27
28
29
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31
Year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
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2010
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Please let us know if you want to receive information on couples tips for improving partnership, workshops and other information on healthy partnership
Yes
No
Current Occupation
Employer
Employer Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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:
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
No
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Cell Phone
Work Phone
Current Problem Checklist
Check any of the following which are problems for you now.
Nervousness
Separation
Drug use
Anger
Sleep
Abuse
Eating
Energy
Loneliness
Communication
Health
Self-esteem
Relationships
Shame
Sadness
Guilt
Addictions
Body image
Depression
sexual identity
alcohol use
self control
anxiety
headaches
legal
emotions
concentration
family
worthlessness
food
parents
feeling inferior
pain
religion/spirituality
losses
nightmares
fears
suicidal thoughts
finances
friends
procrastination
humiliation
memory
decision-making
childhood
trust
sex
felling unsafe
career/work
temper
parenting
not feeling loved
intimacy
panic attacks
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.
Nervousness
Separation
Drug use
Anger
Sleep
Abuse
Eating
Energy
Loneliness
Communication
Health
Self-esteem
Relationships
Shame
Sadness
Guilt
Addictions
Body image
Depression
sexual identity
alcohol use
self control
anxiety
headaches
legal
emotions
concentration
family
worthlessness
food
parents
feeling inferior
pain
religion/spirituality
losses
nightmares
fears
suicidal thoughts
finances
friends
procrastination
humiliation
memory
decision-making
childhood
trust
sex
felling unsafe
career/work
temper
parenting
not feeling loved
intimacy
panic attacks
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 678-487-6916 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 credit card 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 Elena Kim 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 Elena 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 678-487-6916 or
elena@thecouplescollege.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
Insurance
Do you need a superbill for insurance?
Yes
No
What name is on the insurance card?
HIPAA
Please click here to view our HIPAA guidelines.
No Surprises Act - Your Rights as a client of The Couples College
Please click here to review our
No Surprises Act
Policy.
Informed Consent
Please click here to review our entire informed consent document.
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.
Comments
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