Confidential Client Information Form
Please fill out the fields below and submit as part of the new client intake process.

This is a digital intake form - please submit prior to your first scheduled meeting. If you have any questions, contact me directly via email or phone:
Email: mdiben18361@gmail.com
Phone: (573) 424-1998
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First name *
Last name *
Pronouns
E-mail address *
Phone Number *
Address
Date of birth
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Age
Relationship status
Work phone
Referred to this office by
Spouse name (if relevant)
Spouse age (if relevant)
Children names and ages (if relevant)
Briefly describe your reasons for seeking counseling. Include any changes you hope to see as a result of counseling.  *
Briefly list any previous counseling experiences.
Client Rights
1. You have the right to decide not to receive therapy at HCI Counseling Services. If you wish, your therapist will provide you with the names of other qualified therapists.
2. You have the right to end therapy at any time without any moral or legal obligation.
3. You have the right to ask any questions about the procedures used during therapy.
4. One of your most important rights is confidentiality. Within certain limits, information revealed during therapy will be kept strictly confidential and will not be revealed to any other person or agency without your written permission.
5. If you request it, any part of your record can be released to any other person or agencies you designate. Your therapist will tell you whether or not making your record public could be of harm to you.
6. You should also be aware that there are certain situations in which a therapist is required by law to reveal information obtained during therapy to other persons or agencies without your permission. Also, your therapist is not required to inform you of actions taken in this regard. The situations are as follows:

A) If you threaten grave bodily harm or death to another person, the law requires the therapist to inform the intended victim as well as law enforcement agencies.
B) If you have intentions to attempt suicide the therapist can break confidentiality in order to insure your safety.
C) The therapist is mandated by law to report incidents of child abuse and neglect.
Information and Policies
Session Length: Standard counseling sessions are 50 minutes long. The cost of individual, marriage, and family counseling is $90 per session. A $40 fee is assessed based on late cancellations (less than 24 hours notice) as well as missed sessions without notice. This is not applied due to illness or emergencies.

Payment: Payment is due when services are rendered. If you are unable to pay your bill when services are rendered, please inform your therapist in advance in order to make arrangements. 

Insurance: If you plan on using insurance to pay for a portion of counseling please bring policy information, including a contact  number, to the session. There are no additional charges to process forms necessary to make a claim.

It is the policy of HCI Counseling Services to provide services to all persons without regard to race, color, nationality, religion, sex, gender, age, or disability. No person shall be excluded from participation in, or be denied the benefits of any service, or be subject to discrimination because of race, color, nationality, religion, sex, gender, age, or disability.

IF YOU HAVE QUESTIONS AS TO THE ABOVE, ASK YOUR THERAPIST PRIOR TO SIGNING. 

By entering the date and your e-Signature below, and submitting this form, you are declaring that you read, understand, and agree to the above policies.
Full name
Date
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