Client Registration Registro de Información
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Client Information Información de Cliente
Insurance Information Información del Seguro
Cardholder Information Información del titular de la tarjeta
Children Hijos
Mental Health History Historial De Salud Mental
Please List Previous Therapy Sessions Enumere las sesiones de terapia anteriores
Suicide or suicide attempt? ¿Suicidio o intento de suicidio?
Incest or sexual molestation? ¿Incesto or abuso sexual?
Child abuse? ¿Abuso de Menores?
Serious harm to or by another person? ¿Ha estado en peligro de muerte u otra persona?
Major life changes within the past year? ¿Algún cambio drástico en su vida en este año?
Individual Background Information Información Individual
Complete questions to continue Completa preguntas para continuar
Alcohol/Drug History Historial De Alcohol Y/o Drogas
I am an abstainer Practico la abstinencia
I am a social user Soy bebedor(a) social
I am concerned about my use Estoy preocupado(a) con mi consumo
Family/friends are concerned about my use Familia/Amigos están preocupados de mi consumo
I am a recovering alcoholic/addict Estoy recuperandome de alcoholismo/adicción
I am currently in treatment En el presente, estoy en tratamiento
Emergency Contacts En caso de emergencia, ¿A quién nos da la autorización de contactar?
Fees and Billing
Yor are ultimately responsible for the costs of treatment. By your signature below, you acknowledge that you have discussed the costs of therapy with your therapist.
Cancellations and No Shows
Cancellations need to be made 24 hours in advance of the scheduled appointment. You may be charged for appointments cancelled with less than 24-hour notice. Please note that we are not permitted to bill insurance for missed appointments, and therefore you will be responsible for paying for missed appointments.
Emergency Procedures
In the event of an emergency, you can leave an urgent message on our phone system and your therapist will be contacted. If she/he is not available, you have the option to speak with another therapist from the clinic. To leave these urgent messages, follow the instructions given in the greetings. During a life threatening crisis, please call 911.
If you have any questions or concerns about any of the above, please discuss these with your therapist. Thank you.
Type your full name and date into the fields below so that they match the information below the field to sign this document Escriba su nombre completo y fecha en los campos a continuación para que coincidan con la información debajo del campo para firmar este documento
Your Registration is Complete!
Thank you for taking the time to complete this form. Your therapist will be following up with any questions via email.
If you are planning on using our video therapy system, please also fill out this consent form:
Video Therapy Consent Form
