Client Intake

Please complete all the information on this form so that we can know and serve you better. Remember all information will be kept strictly confidential as outlined in our Statement of Understanding.

Required fields indicated by red* (asterisk) must be completed to successfully submit the form.

"*" indicates required fields

CLIENT INFORMATION

Name*

First Middle Last

Date Today

What is your appointment time?*

What is your appointment date?*

Primary Phone*

For you privacy how would you like us to use your Primary phone?*

Send text messages

Leave voice messages

Email*

Address of Client*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Age of Client*

Please enter a number from 1 to 99.

Gender*

Last 4 digits of Social Security number.*

Please enter a number from 0000 to 9999.

Ethnic Background

Current relationship status?

How long?

EMERGENCY CONTACT INFORMATION

Emergency Contact Name*

Emergency Contact Name

Emergency Contact Phone*

Emergency Contact Address

Street Address City State ZIP Code

Emergency Contact Relationship*

ISSUE INFORMATION

Briefly describe what has prompted you to seek our services today.*

INSURANCE, EMPLOYMENT & REFERRAL INFORMATION

Name of Your Employer?

How many years with this employer?

Please enter a number from 0 to 99.

Your Job Title?

Name of Counseling/EAP company?*

Your Employer?*

Provider Authorization #?

Primary Policy Holder Name*

Policy Holder Address (if different then your address)

Street Address City State ZIP Code

Policy Holder Date of Birth*

Medical Card Member ID?*

Medical Card Group #?*

Medical Insurance Provider?*

Medical Card – FRONT

Accepted file types: jpg, jpeg, png, gif.

Please post a camera photo of the Front of your insurance card.

Medical Card – BACK

Accepted file types: jpg, jpeg, png, gif.

Please post a camera photo of the back of your insurance card.

Driver's License – Front

Accepted file types: jpg, jpeg, png, gif.

Please post a camera photo of the front of your drivers license or other state issued id card.

What is your relationship to the employee with the Counseling/EAP benefit?*

Self

Spouse

Dependent

Other

Employee Name*

Name of employee with EAP benefit.

Date of Birth of Employee with EAP Benefit*

Last Four SS# of the primary insured

Please enter a number from 1 to 9999.

MEDICAL INFORMATION

Primary Care Physician Name

Do you receive regular Well Person (Physical) Exams?

Yes

When was your last physical with your doctor?

Approximate date

When was your last visit with a doctor for any reason?

Approximate date

In general, how would you rate your overall health?

Do you talk to your doctor regularly about your health, medication and side effects?

Yes

What medications, vitamins, supplements, and over the counter products are you using for your health?

Please enter all of your medication/supplement names, dosages and usage reasons. For prescription medications please include the dosages.

Do you take your medications as prescribed?

Always

Sometimes

Not taking as prescribed

MILITARY INFORMATION

Veteran

Yes

Experienced Combat?

Yes

When?

SUBSTANCE USAGE INFORMATION

Substances used in the past 12 months*

Please check all the apply currently or in past 12 months.

Alcohol — including all forms of beer, wine, and distilled liquors

Caffeine — coffee, tea, energy drinks, or soda

Cannabinoids — Marijuana, hashish, hash oil, and edible cannabinoids

Nicotine — cigarettes, vapor-cigarettes, cigars, chewing tobacco, and snuff

Opioids — Heroin, methadone, buprenorphine, Oxycodone, Vicodin, and Lortab

Depressants — Benzodiazepines (e.g., Valium, Librium, and Xanax) and Barbiturates

Stimulants — Cocaine, amphetamine, methamphetamine, methylphenidate (e.g., Ritalin), and atomoxetine (e.g., Stratera)

Hallucinogens — LSD, mescaline, mushrooms, or MDMA (e.g., Ecstasy)

None

1) In the past 12 months how often do you have a drink containing alcohol?*

Never

Monthly or Less

2-4 times a month

2-3 times a week

4 or more times a week

2) How many drinks containing alcohol do you have on a typical day you are drinking?*

3) How often do you have four or more drinks on one occasion?*

4) How often in the past 12 months have you found that you were not able to stop drinking once you had started?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

5) How often in the past 12 months have you failed to do what was expected of you because of drinking?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

6) How often in the past 12 months have you needed a drink first think in the morning to "get yourself going?"*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

7) How often in the past 12 months have you had a feeling of guilt or remorse after drinking?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

8) How often in the past 12 months have you been unable to remember what happened the night before because of your drinking?*

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

9) Have you or someone else been injured because of you drinking?*

Yes but not in past year

Yes during the past year

10) Has a relative, friend, doctor or other health care professional been concerned about your drinking and suggested you cut down?*

Yes but not in past year

Yes during the past year

Have you discussed your drinking with a healthcare professional?*

Yes but not in past year

Yes during the past year

First age to use Alcohol*

Please enter a number from 2 to 100.

When you are drinking alcohol what is your preferred drink?*

Beer

Wine

Spirits

What is the size of beer do you normally consume?

12 ounce

16 ounce or pint

24 ounce

40 ounce

What is the approximate quantity of wine do you consume when you are drinking?

5 ounce (standard glass of wine)

8 ounce

12 ounce

750 ml (standard bottle of wine)

More than 750 ml

What is the approximate quantity of spirits do you consume when you are drinking?

1-2 ounces

3-4 ounces

5-10 ounces

more than 10 ounces

How often do you use Cannabis/THC?*

once a day or more

daily to once a week

weekly to once a month

monthly or less

Other

What method do you most often use to consume Cannabis/THC?*

Smoke

Vapor

Ingest

Other

Have you ever discussed your Cannabis/THC usage with a healthcare professional?*

Yes not within past year

Yes within past year

DOMESTIC VIOLENCE INFORMATION

Domestic Violence History*

Domestic violence is a term used to describe offenses committed against an intimate partner, family member, or other individuals within the household.

Physical — when a person uses physical force against another person

Sexual — rape, child sexual abuse, sexual assault, prostitution, female genital mutilation, sexual harassment, sexual bullying and sexual abuse within partnerships.

Economic — unauthorized use of a person’s property, money, or other valuables

Emotional/Verbal — yelling, name-calling, blaming, and shaming. Isolation, intimidation, threats of physical violence

None

When did you last experience the selected domestic violence offense(s)?

Never

0 – 30 days

1 – 12 months

12 – 24 months

Over 24 months

Are you presently in a the domestic violence situation?

Yes

LIFE IMPACT INFORMATION

During the last 30 days, to what extent has your ability to perform your daily activities been impacted by this issue?

During the last 30 days, to what extent has this issue impacted your normal activities with family and friends?

During the last 30 days, to what extent has your physical health interfered with your ability to be as productive as you would like to at work or other daily activities?

How many days in the last 30 days have you had an unplanned tardiness or absence from work?

How has this problem affected your Marriage or Partnership?*

How has this problem affected your Family?*

How has this problem affected your job or school performance?*

How has this problem affected your friendships?*

How has this problem affected your current financial situation?*

How has this problem affected your current legal situation?*

How has this problem affected your health?*

How has this problem affected activity level?*

How has this problem affected your mood?*

How has this problem affected your eating habits?*

How has this problem affected your sleeping habits?*

How has this problem affected ability to concentrate?*

How has this problem affected your parenting?*

How has this problem affected your anger?*

How has this problem affected your spirituality?*

CONSENTS & SIGNATURE

TELEHEALTH APPOINTMENT CONSENT*

Providing counseling services via electronic devices (tablet, computer, telephone, video, chat, text, email, etc.) can make
counseling more convenient in some circumstances. However, the technology used comes with its own special risks
including risks to confidentiality and the possibility of breakdown in the communications devices used. We will always
verify your Identity when use an electronic device. We will have a back up plan if internet is not reliable to try to
complete our meeting by telephone, if that is not a reliable option, we will reschedule the meeting.
This consent is for all telehealth service provided to me by (my Healthcare Provider) Heather Keller at H3 For You, PLLC.
Telehealth is the use of the Internet or Telephone to provide remote mental health care between a Healthcare Provider
and patient(s)/client(s).
Specifically, a mental health care professional will be communicating with me remotely via the Internet using Doxy.me
web-based audio-video software (referred to in this form as Telehealth Appointment). Doxy.me only hosts the software
and does not provide medical advice or information. When Internet service is unreliable the meeting will continue on the
telephone or be rescheduled.
The Telehealth Appointment may be for diagnosis, continuity of care, treatment, or consultation as deemed necessary by
my Healthcare Provider or me.
I understand that during a Telehealth Appointment
— details of my personal medical history and personal health information may be discussed with me and/or other health
care professionals;
— audio, video, or photo recordings containing medical details may be transmitted via secure channels and those details
may become part of my permanent records;
— all confidentiality protections granted to me by various state and federal laws also apply to my care during this
appointment;
— industry-standard network and software security protocols are in place that protect the privacy of the communication
and safeguard my transmitted information against eavesdropping and corruption;
— there may be security and privacy risks associated with Internet-based communications;
— there are benefits and limitations when compared to traditional in-person visit due to the fact that I will not be in the
same room as my provider;
— either my Healthcare Provider or I can discontinue the Telehealth Appointment if either of us feels that the information
obtained through remote communications is not adequate for diagnostic decision-making or for providing the care I
desire;
— In addition to my Healthcare Provider named above, I will be informed of any other person(s) who may be present
during the appointment and have the right to have them leave the viewing and listening area;
— to maintain my privacy, I need to ensure that my viewing and listening areas is limited to myself and any other person(s)
that has a need to participate during the virtual telehealth appointment;
— due to the limitations of telehealth that are out of my control (such as unreliable internet connection), I will call local
authorities (9-1-1) to assist me with any medical emergency;
— I have the right to omit or withhold specific details of my history that are personally sensitive;
— my Healthcare Provider may advise me to seek immediate or additional treatment or determine that there is a medical
emergency and, as such, local authorities may be given my personal details to assist me;
— the communication is privileged and confidential, and I will not record the audio or video without first seeking the
permission of my Healthcare Provider and my Healthcare Provider will not record audio or video.
Therefore, by consenting to this Telehealth Appointment
1. I desire to engage in remote audio-video communications with my Healthcare Provider.
2. I will not record audio or video communications without my Healthcare Provider verbal and written permission.
3. I understand the risks and benefits of using Internet-based communications and that no results can be guaranteed.

4. I acknowledge that if the Healthcare Provider believes that remote communication is insufficient for treatment,
consultation or evaluation, then I will be referred to alternate services or options.
5. I understand that I may be responsible for co-payments, deductibles, and other charges from my Healthcare Provider,
and additional charges may occur for services related to this appointment.
6. I have the ability to ask direct question of my Healthcare Provider about this appointment, including details about the
Healthcare Provider's privacy policy.
7. If my question is not answered to my satisfaction, I have the right to terminate the appointment.
8. I am at least 18 years of age.

I understand Telehealth counseling as described.

PRIVATE-PAY (OPT-OUT) MEDICARE SERVICES*

Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a Medicare beneficiary.

WHY A SPECIAL CONTRACT?
I have not been excluded from providing medical services under Social Security Act Medicare (including sections 1128, 1156, 1892, CFR § 405, subpart D. I, Heather Keller, H3 For You, PLLC have chosen to separate myself (“opt out”) from Medicare. My current opt-out started 01/12/2024, and ends 01/12/2026.

Because I opted out, Medicare requires I have you sign a private-pay medical services contract before I treat you.

WHO PAYS FOR SERVICES? You pay the bill. You will have to use your own money to pay the ENTIRE cost of my services.

ARE THERE CHARGE LIMITS? No, Medicare charge limits DO NOT apply to products or services you receive from me through this private-pay medical services contract. I am able to charge you whatever amount you and I agree to.

WILL MEDICARE HELP PAY? No, Medicare will NOT help pay your bill. Because I separated from Medicare, it is against the rules for you to send a bill to Medicare for my services or ask to send the bill to Medicare for you.

BUT ISN’T THIS A MEDICARE-COVERED SERVICE? Yes and no. Yes, Medicare would pay for the same service from a provider who is connected to Medicare. No, Medicare won’t pay because I have separated myself from Medicare.

WHAT OPTIONS DO I HAVE? You have the right to get your product or service from a provider connected to Medicare or from me, a provider separated from Medicare. Even if you get your product or service from me, you can always get
products and services from providers connected to Medicare. These providers are
not required to have you sign private-pay medical services contracts.

WHAT IF I AM HAVING A MEDICAL EMERGENCY? This contract does NOT cover emergency or urgent care services. If you have an emergency or urgent medical need, ask me for help. It is against Medicare rules for me to have you sign a private-pay medical services contract for emergency or urgent medical services.

WILL MY MEDIGAP OR OTHER SUPPLEMENTAL PLAN HELP PAY? No, Medigap plans WILL NOT help pay for products or services you get from me. If you have some other medical insurance plan, it MIGHT NOT help pay your bill either.

WHAT ELSE DO I NEED TO DO? If you decide to sign this contract, make sure that I also sign the contract. It is also important you get a copy of the contract to keep. This way you will have a copy to look at if you have any questions about the contract in the future.

WILL CMS GET A COPY OF THE CONTRACT? I, the provider, will supply a copy of this contract in the event CMS requests a copy electronically.

I understand Private-Pay (Opt-Out) Medicare Services or I do not qualify for Medicare.

Electronic Signature (Type full name)*

Date Acknowledging Electronic Signature*

__________________________________ _____________
Client Signature Date

__________________________________ _____________
Witness Signature Date

All Required fields indicated by * must be completed to submit the form.