Family Counseling Of Columbus - Appointment Scheduling Form / Information Sheet printable pdf download

Family Counseling of Columbus - Appointment Scheduling Form / Information Sheet

Client One: ___________________________________________________________________________ Birth Date \ Age: __________________\_______

Other Client(s): ________________________________________________________________________ Ages: _________________________________

Responsible Party: _____________________________________________________________________ Home Phone: (

)_____________________

Address:_____________________________________________________________________________________________________________________

Social Security #:____________________________________________________SS# of RP:_________________________________________________

Employer (client 1): _________________________________________________ Work Phone: (

)_________________________________________

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Client one: Married

Single

Divorced

Widowed

Other

# of People in Household:

Other: ______

Who referred you to our Agency? __________________________________________________________________________________________________

FCOC program: provide services to Domestic Violence Victims/Offenders; Are you OK with sharing a space with Domestic Violence clients?

Yes or

Do you have a family member or friend currently attending the Family Center?

Yes

If Yes, Name: __________________________________

Does your employer have a Direct Service Contract with The Family Center?

Yes

Contact/Case Mgr. Name: ______________________________________________________________Phone: (

)____________________________

Authorization # _____________# of visits allowed: ___________ Fee Amount $__________ Staff Initials: _______________ Date: ____________________

If client calls and states has a Direct Service Contract with Children Treehouse , please call and confirm with CTH:

Contact/Case Mgr. Name: ______________________________________________________________Phone: (

)____________________________

DSC Confirmed

Yes

If yes, # of visits allowed: ___________ Fee Amount $__________ Staff Initials: _________ Date: __________________

Do we have permission to call you at home?

Yes

at work?

Yes

May we leave a message for you if you are not available?

Yes

at work?

Yes

When we contact you, may we identify ourselves as The Family Center?

Yes

at work?

Yes

Do we have permission to send mail to your address as listed above?

Yes

Can we E-Mail information pertaining to appt. and treatment?

Yes

No If Yes, E-Mail Address: _________________________________

If you have an emergency, whom can we contact? Name: ___________________________ Relation to you: _______________Phone #: _______________

What brings you to seek counseling at this time?

(Check all that apply)

Depression

Anxiety

Stress

Marital/Couple Problems

Parent/Child Problems

Substance Abuse

Anger Problems

Domestic Violence

Grief

Low self-esteem

Court Ordered:

# of sessions: ____ Referring Agency/or Officer: ______________

(example - fighting with co-worker, friend, neighbor, anyone other than spouse or girlfriend)

DVIP: (men only: for domestic violence with companion) # of sessions: ____ Referring Agency/or Officer: ____________________________________

Other (harassment, stalking, etc.)_____________________________________________________________________________ # of sessions: _______

Would you consider this an emergency?

Yes

If call forward to counselor: _______________________________________________________

Name of Counselor

IF YES, IDENTIFY EMERGENCY:

Suicidal

Wanting to hurt yourself or others

Drug / alcohol intoxication or withdrawal

Hearing or seeing frightening things

Other _______________________________________________________________________________________

Do you have any physical handicaps or disabilities that might restrict your movement to go up and down stairs?

Yes

Would you like assistance reading or filling out the paperwork that will be required at your first appointment?

Yes

Do you have any trouble speaking or hearing?

Yes

Do you have a current or previous Physician or Psychiatrist?

Yes

If Yes, Name: _______________________

Physician

Psychiatrist

Our normal fee is $75.00 per hour. For our clients who cannot afford this amount, the fee can be adjusted to something you can afford, based on a sliding

fee scale. In order to make the fee affordable we need to know your total monthly household income before taxes, and the number of people you support on

this income.

FCOC ADMINISTRATION USE ONLY:

Received –Attached Intake Paperwork

VERIFICATION OF INCOME: ________________________________

Not Received Wil Bring In On 1

Visit

PICTURE ID: Yor N (If no must bring in some form of ID with picture) Form ID (drivers, school, etc):________________________________

Received –Attached Intake Paperwork

Not Received Will Bring In On 1

Visit

Appt. Date:______________ Intake Time: ________ Session Time: _________ Counselor:_________________ FCOC Admin Initials & Date: _________

Reviewed with Client information needed @ Intake