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Name *

Date of Birth *

Age

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Address

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Primary Phone Preferences

Yes, I am willing to receive Voicemail at this number
Yes, I am willing to receive Text Messages at this number
No, please don't leave Voicemail at this number
No, please don't send Text Messages to this number

Alternate Phone Number

When should we use your alternate phone number?

Email *

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Please note: Email correspondence is not considered to be a confidential medium of communication.

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Relationship

(e.g. mother, boyfriend, wife, etc.)

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Are you currently taking any prescription medications?

Have you ever been prescribed psychiatric medication?

Please list any specific health problems you are currently experiencing:

If you have ever attempted suicide, how long ago did it happen?

Are you currently experiencing overwhelming sadness or grief?

Are you currently experiencing anxiety, panics attacks or have any phobias?

Are you currently experiencing any chronic pain?

Do you drink alcohol more than once a week?

Are you currently in a romantic relationship?

What significant life changes or stressful events have you experienced recently?

Please briefly describe your goals for group therapy:

CONFIDENTIALITY POLICY - My name below attests that I have read and understood these policies. *

In general, the law in Florida requires us as a Mental health Practice to protect the confidentiality of information that you communicate to us during the course of your treatment. We can only release information about our work to others with your written permission. Some exceptions to this exist. If you have any questions about this policy, we can review this at any time. The exceptions include, but are not limited to the following situations: DUTY TO WARN AND PROTECT When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. ABUSE OF CHILDREN AND VULNERABLE ADULTS If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. INSURANCE PROVIDERS (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to types of services, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

CLIENT INFORMATION REGARDING FEES AND APPOINTMENTS - My name below attests that I have read and understood these policies. *

We are in network with Aetna. We can accept your Aetna plan's copay. Otherwise, our fees are as follows. Group meeting: $30 Appointment fees are due and payable at the end of each session. Cancellation and no-show fees: Cancellation fee (with less than 24 hours notice): $15 No show fee: $15 Your credit card on file with us will be charged for any no shows, late cancellations, and services rendered. Exceptions may be made for emergencies and for the first occurrence. If you have 2 or more no shows or 3 or more late cancellations (without 24 hour notice) within a rolling 6 month period at the discretion of your therapist may be referred elsewhere. Sessions are usually 45 to 50 minutes long.Sessions generally start on time and end on time so your promptness is appreciated. If you are more than 20 minutes late it will be at the discretion of the provider whether the session will take place or be rescheduled. We take vacations during the year and will give you notice prior to vacation times. If you need to talk between sessions call us at 352-660-4142 and leave a message or email us with some good times to reach you. We usually return calls on the next business day. In case of an emergency, call the Alachua Crisis Center 352-264-6789 or please go to the nearest emergency room.

CREDIT CARD AUTHORIZATION *

I hereby authorize Gainesville Healing House to keep my credit card on file and use for payment of balances owed. I agree to be charged for my sessions at the end of each session. If you are not able to let us keep your card on file, please discuss this with your therapist.

Cardholder Name *

Billing Address *

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Address Line 2

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Credit Card Type *

Visa
Mastercard
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Card Number *

Expiration Date *

CVV security code: *

Usually a 3-digit code on the back of the card.

My name below attests that I have read and understood these policies. *

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Group Therapy for Depression

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