Intake Forms

Family Institute, P.C.
Supporting the Family™

Quick Access

-Intake Forms

(forms may not be up to date)

-CoDA Registration

-Prepare Registration

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-Calendar

-Privacy Policy

Codependency and

Boundaries Weekend:

Minimum = 6; Limit =12

$200 per person

-Upcoming Workshop Dates:

-Call 503-601-5400

**CoDA Registration**

**Area Motels**

Portland Area CoDA Mtgs

503-601-5400

503-601-5410 Fax

-Phone: for 2012 dates

-PREPARE Registration

-From Portland

-Directions from Salem

Licensed MH Professionals:

-Linda Beldin-Korter, LCSW

-Joe Cereghino, Psy.D.

-John Crippen, LMFT

-Bob Davidson, LMFT

-Wendy Galambos, LPC

-Naomi Hunsaker, LPC

-Brooke Miller, LCSW

-Kathy Hardie-Williams, LPC

Registered Interns:

-Pam Beck, MA

Grad Students:

Foundation Seminars

Life Renewal Institute

Love Takes Time

Self-Injury

Sexual Addiction

SexHelp.com

Sexual Anorexia

The Bridge to Recovery -KY

Recovery Resources

Marriage Counseling Blog

Marriage Friendly Therapist

Am Assoc for Marriage

and Family Therapists

LMFT Therapist Locator

Edwin Noyes, MD, MPH

"Exposing Spiritualistic

Deceptions in Health and

Healing." Book resource

Intake Forms

It would be helpful to have all forms filled out before therapy begins. The forms are created in Acrobat Reader format. If you do not have that program, you may download that program free. If you have problems downloading any of the files in Acrobat, you are probably using an older version, like 4.0. Most the forms are in version 5. Click on the Acrobat Reader icon to get the latest version of Acrobat Reader.

You can fill out the forms on your computer, then print them out. However, you do not have to fill the forms out on the computer. You can send the forms directly to your printer. The Instruction Checklist would be helpful for you to print out and use as a guide.

Intake Forms for Bob, Wendy, Joe, John, Naomi, Kathy, Linda BK, Brooke, Audrey	Intake Forms for Pam Beck	Other Forms for all clinicians	Handouts for all clinicians






The above and below are Related Forms and Handouts: (forms, links might not be up-to-date)

Bob's	-Form:	-Couple Agreement -Couple/Family Therapy Contract	-All couples need to evaluate and sign if interested -Must be signed for any couple therapy or family therapy
Bob's	-Handouts:	-Curriculum Vitae -Professional Disclosure Statement	-For your information -Please printout and read, A must for all clients
Joe's	-Forms: -Handouts:	-Couple Agreement -Couple/Family Therapy Contract -Resume -Professional Disclosure Statement	-All couples need to evaluate and sign if interested -Must be signed for any couple therapy or family therapy -For your information -Please printout and read, A must for all clients
Naomi's	-Forms: -Handouts:	-Couple Agreement -Couple/Family Therapy Contract -Resume -Professional Disclosure Statement	-All couples need to evaluate and sign if interested -Must be signed for any couple therapy or family therapy -For your information -Please printout and read, A must for all clients
John's	-Forms -Handouts	-Couple Agreement -Couple/Family Therapy Contract -Resume -Professional Disclosure Statement	-All couples need to evaluate and sign if interested -Must be signed for any couple therapy or family therapy -For your information -Please printout and read, A must for all clients
Brooke's	-Handouts	-Professional Disclosure Statement	-Please printout and read. A must for all clients
Wendy's	-Forms: -Handouts:	-Couple Agreement -Couple/Family Therapy Contract -Resume -Professional Disclosure Statement	-All couples need to evaluate and sign if interested -Must be signed for any couple therapy or family therapy -For your information -Please printout and read, A must for all clients

Instruction Checklist	Print this out. It will help explain which forms you need.
Contract	Everyone must sign and date. Print second copy for yourself. Click on contract under desired therapist because contracts are different. If you have questions about the contract, you may raise them with the therapist at your first session (or for that matter, any time).
Intake Form	A must for all new clients to fill out. One form per family, designating the identified patient (IP) for billing purposes. If you phone, this information is gathered by the office staff or therapist.
BioPsychoSocial History	This may take up to 1 minute to download, per page (4 pages). This history is very helpful and will save the therapist a lot of time, reserving the therapy session for discussion and conversation about the presenting problem and your needs. If marital, both need to fill out this form.
Medical History	Each person fill out. This information is helpful to make sure that we are treating the whole person.
HMO Worksheet	This Insurance Verification Form is for your assistance to help you find out your insurance coverage. There are suggested questions that you could ask and helpful things that you need to know when dealing with your HMO.
Handouts:
Managed Care Notice	Insurance Clients: Read, Information about insurance billing and confidentiality.
Professional Disclosure Statement	Each counselor is required to provide this statement about themselves. please read and printout for your information. Print out the one on your counselor.
PR Brochure/Flier	This is our brochure that you may print out. Share with a friend. This tells more about us. Our graduate student has a separate flier.
What You Should Know	"What You Should Know About Marital and Family Therapy" Handout
Additional Forms:
Release of Confidentiality	For sharing records and/or treatment goals and outcomes between counselors, lawyers, pastors, teachers, non-custodial parent, etc.
Child Intake Form	Four pages, parent fills out on child's behavior, desired changes, problem areas, etc. Form can be typed, then printed out or printed out and then filled in. This form is if the child is the identified client.
Couple: 3 Questions	These three questions are most helpful when you come in as a couple. Each spouse fills one out. This form will help you get your thoughts organized and clarify what your needs are in the relationship.
Couple: Questionnaire	These questions might be helpful to clarify your thinking as a couple. If you desire, fill out and answer the questions that you think are significant and important. Fax ahead of session or bring to your next session.
Couple Agreement	When couple come in for therapy, they find this agreement helpful. It is an agreement between the couple that they want their therapy to remain confidential under all circumstances. Print out the one with your counselor.
DBT Diary Card	For those attending the DBT Class.