Please provide as much of the following information as you can and submit it at the end. Please note that if you have submitted this form, you will not have a similar form to fill out at your first session with me, saving time and trees:

Client Information:

            Name
   Date of Birth
             Sex Male Female
       Soc. Sec. #

Address, etc.:

  Street Address
 Address (cont.)
            City
  State/Province
 Zip/Postal Code
         Country
      Work Phone
      Home Phone
             FAX
          E-mail
             URL

Primary Care Physician (PCP):

            Name
           Title
    Organization
  Street Address
 Address (cont.)
            City
  State/Province
 Zip/Postal Code
         Country
      Work Phone
             FAX
          E-mail
             URL

Client's Legal Guardian:

            Name
           Title
    Organization
  Street Address
 Address (cont.)
            City
  State/Province
 Zip/Postal Code
         Country
      Work Phone
      Home Phone
             FAX
          E-mail
             URL

Primary Insurance Information:

Secondary Insurance Information:

Acknowledgement of the Privacy Practices Information provided in this form: Client Information and Office Policy Statement

Choose one of the following options:

I choose NOT to receive an official paper copy of Privacy Practices.
I choose to receive an official copy of Privacy Practices at my first appointment.

Assignment of Counseling Benefits:

BY SUBMITTING THIS FORM, you hereby assign payment of insurance benefits, including but not limited to Medicaid health maintenance organizations or preferred provider organizations, to be paid directly to Debbie Urban, LPC, for treatment charges and on your behalf.

Future Authorizations for Sessions:

SUBMITTING THIS FORM will also allow Debbie Urban, LPC, to complete the necessary paper work to request additional sessions from your health insurance/third party provider if additional sessions are necessary.

In your own words, please explain what your concerns are:

Describe the history of the problems, past treatment, hospitalizations, or anything you think is relevant:

Would you like me to respond to this form?

Yes
No

INFORMED CONSENT FOR TREATMENT

BY SUBMITTING THIS FORM BELOW, you are requesting treatment by Deborah (Debbie) Lee Urban, who is a Licensed Professional Counselor in Missouri and a National Board Certified Counselor. You consent to routine assessment evaluations and counseling as deemed necessary. You understand that Debbie Urban LPC makes no guarantee as to the results of treatment or evaluation. The therapy process is one in which you seek to understand yourself, your feelings, and your concerns more clearly, and to make changes in your life as a result of what you have learned. The role of the therapist in this process is to help you gain a different perspective on yourself, your feelings and your life. The therapist will seek, first, to get to know you so that she can better understand your concerns. You will aid the therapist by being open and honest in your sessions and providing as much information as you can concerning the issues that trouble you. Occasionally, the therapist may say things that you find difficult to hear. Your therapy goals will best be achieved if you can remain open to emotions, insights, and ideas, which may be different than what you have experienced before. Because the therapy process sometimes involves an examination of aspects of yourself, which have previously remained hidden, you may be surprised by the intensity of new emotions. Be assured that this is a normal part of healing and change that occurs through therapy.

BY SUBMITTING THIS FORM BELOW, you are certifying that you have read the Client Information and Office Policy Statement, have completed the information to the best of your ability, and accept, understand, and agree to abide by the contents and terms of this agreement, and further, consent to participate in evaluation and/or treatment, that you may withdraw from treatment at any time, and that you agree to be financially responsible for all fees that are not covered by a third party.

Thanks for using this. I hope it was not too redundant.