Journey of Hope Client Intake Form
Journey of Hope
37899 W 12 Mile Road
Suite B-250
Farmington Hills, MI 48331

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Email *
Name of Client *
Briefly describe what brings you to counseling. What is stressing you out the most in your life right now? *
IDENTIFYING DATA
Thank you for trusting us in helping you in your journey. Please complete this intake information and hit the submit button at the very end......That's it!  We are really looking forward to supporting and working with you.
Payment Method *
What type of service are you interested in? *
Insurance Policy Number *
Birth Date *
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Address: Street City, State & Zip *
Client/Student Phone Number *
School
Grade *
Is the client currently taking any medication? If so, what is it for, how long and how often has it been prescribed for? *
Is anyone concerned about the clients use of alcohol or substance abuse? Please explain. *
Name of Father *
Birth Date *
MM
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DD
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YYYY
Address: Street City, State & Zip *
Father Phone Number *
Email *
Is the father currently taking any medication? If so, what is it for, how long and how often has it been prescribed for? *
Have you (the father) or anyone close to you ever had concerns with your alcohol or substance use? If yes please describe. *
Employer & Employer Address *
Name of Mother *
Birth Date *
MM
/
DD
/
YYYY
Address: Street City, State & Zip *
Mom Phone Number *
Email *
Is the mother currently taking any medication? If so, what is it for, how long and how often has it been prescribed for? *
Have you (the mother) or anyone close to you ever had concerns with your alcohol or substance use? If yes please describe. *
Employer & Employer Address *
Indicate below the current situation regarding custody of the child:   *
Will he/she who has custody of the child agree to treatment for the child? *
I understand that at least one parent or legal guardian must accompany the minor/ child to their first appointment and to any subsequent appointments, until discussed with and agreed upon with the therapist in charge of treatment.  *Type your name to serve as your electronic signature.
Signature: (Mother/Legal Guardian)  *Type your name to serve as your electronic signature. *
Signature: (Father/Legal Guardian)  *Type your name to serve as your electronic signature. *
HEALTH INFORMATION
Client's Primary Care Physician Name *
Please describe CURRENT illness or medical  problems, and the doctor who is treating the client. *
Please describe PAST illness or medical  problems, and the doctor who is treated the client. *
Has the client ever had significant changes in appetite or weight, or an eating disorder? If yes, please explain. *
Does the client drink alcohol? If yes,  how much on a weekly basis? *
Does the client use drugs (including marijuana & prescription medications)? If yes, how much on a weekly basis? *
Has the client experienced sleeping problems within the last 6 months? If yes please explain. *
Has the client gone to psychotherapy or counseling before? If yes when and where? Please explain. *
Has the client ever attempted suicide before or expressed suicidal thoughts? If yes when and where? Please explain. *
Has anyone in the family attempted suicide before or expressed suicidal thoughts? If yes when? Please explain. *
List all medications the client is taking. *
FAMILY HISTORY *
What do you hope to get out of counseling? *
Name of relative or responsible party in case of emergency (Name, address, cell phone, email) *
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you can be disclosed and how you can get access to this information.

OFFICE CIVIL RIGHTS

Most of us feel that our health information is private and should be protected. That is why there is a federal law that sets rules for health care providers and health insurance companies about who can look at and receive our health information. This law, called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), gives you rights over your health information, including the right to get a copy of your information, make sure it is correct, and know who has seen it.

Get It. You can ask to see or get a copy of your medical record and other health information. If you want a copy, you may have to put your request in writing and pay for the cost of copying and mailing. In most cases, your copies must be given to you within 30 days.

Check It. You can ask to change any wrong information in your file or add information to your file if you think something is missing or incomplete. For example, if you and your hospital agree that your file has the wrong result for a test, the hospital must change it. Even if the hospital believes the test result is correct, you still have the right to have your disagreement noted in your file. In most cases, the file should be updated within 60 days.

Know Who Has Seen It. By law, your health information can be used and shared for specific reasons not directly related to your care, like making sure doctors give good care, making sure nursing homes are clean and safe, reporting when the flu is in your area, or reporting as required by state or federal law. In many of these cases, you can find out who has seen your health information. You can: Learn how your health information is used and shared by your doctor or health insurer. Generally, your health information cannot be used for purposes not directly related to your care without your permission. For example, your doctor cannot give it to your employer, or share it for things like marketing and advertising, without your written authorization. You probably received a notice telling you how your health information may be used on your first visit to a new health care provider or when you got new health insurance, but you can ask for another copy anytime. Let your providers or health insurance companies know if there is information you do not want to share. You can ask that your health information not be shared with certain people, groups, or companies.

If you go to a clinic, for example, you can ask the doctor not to share your medical records with other doctors or nurses at the clinic. You can ask for other kinds of restrictions, but they do not always have to agree to do what you ask, particularly if it could affect your care. Finally, you can also ask your health care provider or pharmacy not to tell your health insurance company about care you receive or drugs you take, if you pay for the care or drugs in full and the provider or pharmacy does not need to get paid by your insurance company. ••

Ask to be reached somewhere other than home. You can make reasonable requests to be contacted at different places or in a different way. For example, you can ask to have a nurse call you at your office instead of your home or to send mail to you in an envelope instead of on a postcard.

Your Health Information Privacy Rights 2
•If you think your rights are being denied or your health information is not being protected, you have the right to file a complaint with your provider, health insurer, or the U.S. Department of Health and Human Services. To learn more, visit www.hhs.gov/ocr/privacy/.

Notice of Privacy Practices                              
 Receipt & Acknowledgement of Notice
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Journey of Hope Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Marie Schluter, LMSW, Ed.S. at 248-921-4614. *
 Signature or Parent, Guardian or Personal Representative​ (if you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.). *
Medical Insurance Card
Please take a picture of your medical insurance card - front and back, and email it to: Schluter12@gmail.com Thank you!
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