Client Contact Information Form
Angie Simonton LCSW
306 Pine Street Suite 500
Please complete the following form and return via email at firstname.lastname@example.org
Referred by: ________________________________________
Name of Client: ______________________________________
Date of Birth: ___________ Age____
If Client is a minor (under 18), please list BOTH Parents’ names and Work/Home phone numbers, and also list Step parent(s)’ names and contact information, if applicable.
I understand that in order for Ms. Simonton to work with a minor child that all guardians are required to give verbal and written agreement of counseling. Also a copy of current custody paperwork is required.
Marital Status of Client: (circle) Single, Married, Life-Partner, Divorced, Separated Widow/er, Living with a partner
Address of Client: __________________________________________________________________________________________
Email address of client or guardian(s)_______________________________________________________________________
Name of Client’s insurance and Type of plan :________________________________________________________________________
Whose name and date of birth is the Insurance in:____________________________________
Insurance member number: ________________________________________
Insurance Group number: ________________________________________
Please Attach An Image of the front and back of the Insurance card for verification of Benefits.
Is the client attending school? If so which school and what grade? __________________________________________________________________________________________
Is the client employed, if so where? __________________________________________________________________________________________
Phone Numbers of Client or Legal Guardian(s): Home______________________ Cell___________________Work_________________
Is it ok to leave messages on voicemail?
Name/Phone number of Emergency Contact: ________________________________________________________________________________
By completing this I am giving Ms. Simonton the ability to contact the above person(s) in an Emergency Situation.
Please initial for Agreement __________________
Pharmacy used and phone number:_________________________________________________________________________________
Medications and prescribing physician:__________________________________________________________________________________________________________________________________________________________________________
Reasons the client is seeking therapy services at this time? Please be as specific as possible. If you require more space feel free to write on an additional page. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What would you like to gain from therapy?____________________________________________________________________________________________________________________________
Has the client been diagnosed with a mental health issue? If so, what is the diagnosis and who diagnosed this:_____________________________________________________________________________________________________________________
Is the Client working with a therapist at present or has the client been in therapy in the past? If so , when and with which therapist: ________________________________________________________________________________
Has the client been psychiatrically hospitalized before? If so when are where? _______________________________________________________________________________________________________________________________________
I am willing to sign a release of information for Ms. Simonton to speak with my Primary Care Physician, Other Medical Providers, and School (if needed). Please initial ________________
I understand that Ms. Simonton does not provide: couples counseling, divorce mediation, custody mediation, parent coordination services, nor is she a court appointed expert. However in the event that Ms. Simonton is called to court to for a case you are involved in, she charges 250.00 an hour. Please initial ____________________
I have or will review Ms. Simonton’s Information on her website, http://www.angiesimontonlcsw.org under the pages “Important Information” and “Being Honest about Therapy.”
Initial for agreement _________________
I understand that Ms. Simonton uses a medical biller. I am agreeable to her sharing my information with the billing agency for collection purposes. If I am under Ms. Simonton’s care I will sign a release of information for this.
Initial for agreement____________________
I understand that if my insurance does not cover treatment with Ms. Simonton that her fees are 175.00 for the initial session and 105.00 for every following session. Therapy sessions last 50 minutes to an hour. I understand that I am ultimately responsible for any payments, copayments, and deductibles due. Ms. Simonton expects payment at the end of each session unless insurance is verified for payment. I understand that Ms. Simonton may negotiate a sliding fee scale in the event that therapy is not covered by my insurance plan or I would prefer to not use it. I understand that this is something that i will need to discuss with Ms. Simonton in person. I understand that the completion of this form does not guarantee treatment under the care of Angie Simonton LCSW-BACS. But it is instead a request for the most appropriate treatment. If Ms. Simonton is unable to provide treatment at this time, she will provide an appropriate professional referral to someone who can.
Signature and date of completion
(Updated version 11/7/2017).