Beverly Ventura, M. A.
Marriage, Family Therapist
27281 Las Ramblas Suite 200
Executive Suites Mission Viejo, CA 92691
CLIENT INTAKE INFORMATION AND TREATMENT CONTRACT
Name_____________________________________ Home Phone________________
Address_________________________________ Office Phone_______________
City___________________________ Zip Code___________ Cell Phone_____________
Where may I phone you and leave you messages? Work____ Home___ Cell_________
May I text you? Yes__________ No____________
Date of Birth month/day/year____________ Current Age_________ Employer____________________________________
Martial Status__________________ Life Partner_________________ How Long_________
Spouse’s Name _______________Life Partner’s Name_______________
Spouse/Life Partner Cell_____Office_________
Date of Birth month/day/year_________________Age_____________
Where may I leave a phone message? Work______Home________Cell________
Children’s Names and Ages_________________________________________________
Family Physician ________________________________________________Phone_____________
Known Health Problems_______________________________________________________
Reason for Requesting Services_________________________________________________________
Prior Therapist and Treatment Dates_________________________________________________________________
Prior Life Coach and Dates________________________________________________________
May I contact you by email? Yes _______No______________
Email is not always guaranteed to be private. Please initial_______
Name of Person Who Referred You_________________________________
If Internet then website where you found my name__________________________
PLEASE READ THE FOLLOWING CAREFULLY. Your signature indicates you have read and have understood all of the items below.
PAYMENT FOR SERVICES
It is expected that all clients’ accounts will be kept current. PAYMENTS FOR PROFESSIONAL SERVICES ARE DUE AT THE TIME THE SERVICE IS RENDERED.
The total fee is the ultimate responsibility of the client.
I accept cash, checks or credit cards. If you pay by credit card the charges will show up on your credit card as SquareUp, Beverly Ventura MFT.
All returned checks and denied credit cards will be charged the original fee plus 20 % for bank fees.
24 HOUR NOTICE
TWENTY- FOUR HOUR NOTICE IS REQUIRED TO CANCEL AN APPOINTMENT.
If you do not give proper notice it is considered a no show. You will be charged $50.00 the missed session if proper notice is not given.
TERMINATION OF TREATMENT
If you are going to terminate treatment, you agree to discuss termination of treatment with the therapist and to meet with the therapist at least one time after announcing your intent to leave treatment.
Three (3) or more cancellations and /or 2 no shows may result in termination of treatment.
A session is 45 minutes in length, unless we mutually agree to sessions of shorter or longer duration, and mutually agree to a proportionate fee for the varied time duration of sessions.
FEE FOR SERVICE
The fee for service is $ 150.00 for a 45 minute session. Couples are $160.00
Payment is to be made in full with cash, check or credit card at the time of the session, if you don’t have insurance.
Therapy is a significant personal and financial commitment. Please do not hesitate to discuss financial matters with me.
In the event your insurance does not pay the agreed upon charges due to services not covered, deductible not met at the time of the services rendered, or cancellation of policy, as the client, you will be responsible for full payment at the time of the session.
Before services are rendered you must verify your services with the insurance company and be prepared to show insurance card and know your co pay or deductible.
You will be responsible for full payment at the time of services rendered for the first session if you fail to verify with insurance company ahead of appointment.. My insurance company is
___________________ . My Co- payment due at the time of each session is ___________________.
LIMITS OF CONFIDENTIALITY
All information given during treatment including psychological testing is held in the strictest confidence,
and no information will be shared without the client's written permission to release all or part of this information to a specified person, persons, or agency.
HOWEVER, THERE ARE SOME EXCEPTIONS TO THE ABOVE STATEMENT AS REQUIRED BY LAW:
. When the client threatens suicide, the law demands that the therapist report this information to the appropriate legal authorities and someone close to the client who can possibly help at the time of the threat.
. When the client threatens harm to someone(s) including murder, assault, and /or physical harm, the laws demand the therapist report this situation to the appropriate legal authorities.
. If the client reports his/her involvement in any act against a child /senior which is considered abuse of that child/senior, including excessive physical beating, neglect, and/or molestation;
or if the client/senior reports knowledge of such an act by another, the law mandates that the therapist report this involvement or knowledge to the appropriate legal authorities.
. In litigation, where your mental health is an issue, your therapist may be subpoenaed to court and required to reveal the status of your mental health.
Please sign below indicating that you have read the above statements and understand the contents and the ramifications.
Signing below also indicates that you have read and understood the above statements concerning your financial responsibilities and that you agree to them.
In signing below you also agree to the limits of confidentiality and will not hold Beverly Ventura liable for breach of confidentiality under the conditions stated above.
If any financial problems or difficulties in meeting the above arise, they should be brought up and discussed so they can be understood and resolved, if possible, in a mutually satisfactory way.
previous therapy yes no if so, name ___________________________ number______________________
How would you rate your physical health? excellent very good satisfactory unsatisfactory poor
How would you rate your sleeping habits? excellent very good satisfactory unsatisfactory poor
How many times a week do you generally excercise? ______________________________________
What types of exercise?_______________________________________________________
List any issues with eating or appetite?_________________________________________________________
Are you currently experiencing any overwhelming grief or sadness? yes no
Are you currently experiencing any panic attacks, anxiety or phobias? yes no
Are you experiencing any chronic pain? yes no
Do you drink alcohol more then once a week? yes no
How much _________________________
Do you take recreational drugs? Yes no Types________________________
Are you currently in a romantic relationship? yes no
On scale of 1-10 how do you rate it ?
What significant or stressful events have you experienced lately?
Family Mental History
Alcohol abuse yes no
Anxiety yes no
Depression yes no
Domestic Violence yes no
Eating Disorders yes no
Obesity yes no
OCD yes no
Schizophrenia yes no
Suicide Attempts yes no
Are you employed? yes no
Do you like your job? yes no
Is there anything stressful about your job?______________________________________________
Do you consider yourself to be spiritual? yes no
What do you consider to be your strengths?____________________________________________________
What do you consider to be your weakness?______________________________________________________
What would you like to accomplish in therapy or coaching? ____________________________________________
Client Signature _________________________________Date______________
Parent Signature_________________________________ Date_______________
Beverly Ventura M.A.MFT 40721____________________Date____________
HIPPA Privacy Practices
I have been and always will be totally committed to maintaining your confidentiality. I will only release information about you in accordance with HIPPA policies, state, and local laws.
Your mental health information may be disclosed to other health care professionals for the purpose of treatment.
My duty as your Therapist
I am required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. I am required to abide by the privacy policies and practices that are outlined in this notice.
Your health information may be used to seek payment from your health insurance company, from other sources of coverage, or from credit card companies that you may use to pay for services.
For example, your health plan may request and receive information on dates of servie, the services provided, and the medical condition being treated.
In the event of reported violence, or life threatening dangers, your health information may be disclosed to law enforcement investigations,and to comply with government mandated reporting.
Other Uses and disclosures that require authorization
Disclosure of your mental health information or its use for any purpose other than those listed above require your specific written authorization.
If you change your mind after authorizing a use or disclosure of your information, you must submite a written revocation of the authorization.
However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified me of your decision to revoke
You have certain rights under the fedeeral privacy standards.
The right to request restrictions on the use and disclosure of your protected information.
The right to receive confidential communications concerning your medical condition and treatment.
The right to inspect and copy your protected health information.
The right to amend or submit corrections to your protected health information.
The right to receive an accounting of how and to whom your protected information has been disclosed.
The right to a printed copy of this notice.
Request to Inspect Protected Health Information
You may generally inspect or copy protected health information that I maintain which goes to insurance companies. The request must be made in writing. Your request may
or may not be granted, depending upon the reasoning for disclosure.
You may contact me for further information concerning my privacy practices.
If you would like to submit a comment or complaint about my privacy practices, you can do so by sending a letter and your concerns to my office. If you believe your privacy rights have been violated.
You will not be penalized or otherwise retaliated against for filing a complaint.
HIPPA practices are on my webiste for copying if needed.
If you have any questions or concerns, please discuss them with me.
Please sign stating you understand Federal, State, Local HIPPA laws.
I the undersigned, hereby acknowledge that I read the foregoing engagement letter and HIPPA policy.
The information I provided is true and correct, and that I consent to therapy upon the terms and conditions outlined herein.
If client is a minor, an authorized parent must sign the HIPPA form.
Client Signature_______________________________ Date____________