Support

1. Client Information Form

Personal Information:

Name

Date

Gender Identity

Preferred Pronouns

Address

Phone Number

Email

Emergency Contact (Name & Phone Number)

Medical History:

Current Medical Conditions

Past Medical Conditions:

Allergies:

Primary Care Physician:

Phone Number

Address

Phone Number

Mental Health History:

Current Mental Health Concerns:

Past Mental Health Diagnoses:

Previous Therapy Experience:

If yes, please provide details:

4. Substance Use Disorder History:

Substances Used (Past/Current):

Length of Use:

Treatment History (e.g., Rehab, Counseling):

If yes, please provide details:

5. Family History:

Mental Health Conditions in Family:(Required)

Substance Use Disorders in Family:(Required)

Other Relevant Family History:(Required)

6. Prescribing Physician Information:

Name

Specialization:

Phone Number:

Email Address:(Required)

Medication(s) Prescribed:

7. Medication List:

Current Medications

Dosage

Prescribed By

Purpose of Medication

8. Payment Information

Payment Method:

Other (please specify):

Session Fees:

Individual Therapy (50 minutes)

Price:

Per Session

Sobriety Support Services: Please see the provided list for detailed information and pricing on specific services.

Educational Sessions (1 hour)

Price:

Per Session

Cancellation Policy:

Please provide at least 24-hour notice for cancellations. Cancellations made with less than 24 hours’ notice will incur a fee of $120.00 .

Payment Policy Statement: Becalm Counseling and Sobriety Support Services operates on a private pay basis and does not accept insurance. All session fees are the responsibility of the client and must be paid at the time of service. It is the client’s responsibility to seek reimbursement from their insurance provider if they choose to do so, but we do not bill insurance companies directly.

Acknowledgment: I acknowledge that I have read and understand the payment policy, and I agree to the terms outlined regarding session fees and payment methods.

Client Signature:

9. Google Meet Information

Session Link:

Sessions will be conducted via Google Meet. Please use the following link for all scheduled sessions:

Instructions:

You will receive an email reminder with the Google Meet link 24 hours before your scheduled session.
Ensure your internet connection is stable and that you are in a private, comfortable space for your session.
Please log in 5 minutes before your session begins to ensure everything is working properly.

10. Informed Consent

Introduction:

Welcome to Becalm Counseling and Sobriety Support Services. This document provides important information regarding your therapy and the therapeutic relationship. Please read carefully and sign at the end.

Therapeutic Process:

Therapy is a collaborative process where we work together to address the issues that brought you here. The goal is to help you understand and manage your emotions, thoughts, and behaviors in a healthier way.

Confidentiality:

All information shared in therapy is confidential. This means that I will not disclose any information about you without your written consent, except in situations where I am legally obligated to do so (e.g., risk of harm to yourself or others, child or elder abuse).

Risks and Benefits:

Therapy can have both benefits and risks. While therapy often leads to positive outcomes such as improved relationships and better coping strategies, it can also bring up uncomfortable emotions or memories. Your participation is voluntary, and you have the right to withdraw from therapy at any time.

Records:

I will maintain records of your sessions, which are kept confidential and secure. You have the right to access your records upon request.

Fees and Payment:

Session fees are to be paid at the time of the session through the chosen payment method.

Communication:

I may communicate with you via phone, email, or text. Please be aware that electronic communication is not 100% secure, and confidentiality cannot be guaranteed. By signing this consent, you acknowledge and accept the risks involved.

Termination:

You may choose to end therapy at any time. It is recommended that we discuss termination during a session to provide closure and discuss future resources.

Consent:

By signing this document, you consent to participate in therapy with Katherine Murphy, LMHC. You acknowledge that you have read and understand the information provided and agree to the terms outlined.

Client Signature:

Date:

11. HIPAA Privacy Notice

This notice describes how your medical information may be used and disclosed and how you can get access to this information. Please review it carefully.

Use of Information:

Your health information may be used to provide treatment, obtain payment for services, and conduct healthcare operations.

Your Rights:

You have the right to request restrictions on certain uses and disclosures of your information.
You have the right to inspect and obtain a copy of your health information.

Contact:

If you have any questions about this notice, please contact Katherine Murphy at [Insert Contact Information].

Acknowledgment of Receipt of Privacy Notice:

Client Signature:

Date:

12. Emergency Contact and Safety Plan

Emergency Contact Information:

Name:

Relationship:

Phone Number:

Safety Plan:

In case of a mental health emergency, please contact one of the following:

National Suicide Prevention Lifeline: 1-800-273-8255
Crisis Text Line: Text HOME to 741741
Go to the nearest emergency room

Client Acknowledgment: I acknowledge that I have received and understand the information provided and have a safety plan in place.

Client Signature:

Date:

13. Authorization to Release Information

Purpose:

This form authorizes Katherine Murphy, LMHC, to release and exchange confidential information with the following individual(s) or agency(ies):

Recipient(s):

Name/Agency:(Required)

Contact Information:

Purpose of Release:

Coordination of Care

Other (please specify):

Client Authorization: I authorize the release of information as described above.

Signature

Date:

14. Diversity Statement

At Becalm Counseling and Sobriety Support Services, we are committed to creating an inclusive and welcoming environment for all clients, regardless of race, ethnicity, nationality, gender identity, sexual orientation, age, religion, socioeconomic status, or ability. We believe that every individual brings unique experiences and perspectives to therapy, and we honor and respect those differences in our practice. Our goal is to provide culturally competent care that acknowledges and supports the diverse backgrounds of our clients. We strive to foster an atmosphere of acceptance and understanding, ensuring that all clients feel valued, heard, and empowered on their journey toward healing and personal growth.

15. Indiana State Residency Confirmation

Residency Confirmation: By signing below, I confirm that all individual therapy sessions with Katherine Murphy, LMHC, will be attended from within the state borders of Indiana. I understand that this is a requirement for receiving therapy services through Becalm Counseling and Sobriety Support Services.

Client Signature:

Date:

16. After-Hours Communication Policy

After-Hours Communication: Please note that Katherine Murphy, LMHC, will be unable to respond to voicemails and texts after business hours. Any calls or texts received after business hours will be answered on the next business day. For urgent matters, please refer to your safety plan or contact emergency services.

Client Acknowledgment: I acknowledge that I have read and understand the after-hours communication policy.

Client Signature:

Signature

Date

This completes the intake paperwork for Becalm Counseling and Sobriety Support Services. Please ensure all sections are completed, signed, and returned prior to your first session. If you have any questions or require further assistance, feel free to reach out using the contact information provided.

Intake Paperwork for Becalm Counseling and Sobriety Support Services

1. Client Information Form

Personal Information:

Medical History:

Mental Health History:

4. Substance Use Disorder History:

5. Family History:

6. Prescribing Physician Information:

7. Medication List:

8. Payment Information

Session Fees:

Cancellation Policy:

Acknowledgment: I acknowledge that I have read and understand the payment policy, and I agree to the terms outlined regarding session fees and payment methods.

9. Google Meet Information

Instructions:

10. Informed Consent

Introduction:

Therapeutic Process:

Confidentiality:

Risks and Benefits:

Records:

Fees and Payment:

Communication:

Termination:

Consent:

11. HIPAA Privacy Notice

Use of Information:

Your Rights:

Contact:

Acknowledgment of Receipt of Privacy Notice:

12. Emergency Contact and Safety Plan

Emergency Contact Information:

Safety Plan:

Client Acknowledgment: I acknowledge that I have received and understand the information provided and have a safety plan in place.

13. Authorization to Release Information

Purpose:

Recipient(s):

Purpose of Release:

Client Authorization: I authorize the release of information as described above.

14. Diversity Statement

15. Indiana State Residency Confirmation

16. After-Hours Communication Policy

Client Acknowledgment: I acknowledge that I have read and understand the after-hours communication policy.

Client Signature: