Policies and Procedures for Psychotherapy Services

The content of sessions is confidential, unless otherwise required by law, e.g., in cases of physical/sexual abuse of a minor, or cases where an individual is a physical threat to self or others.

When more than one family member is a client, every effort is made to preserve privacy among family members, but confidentiality cannot be guaranteed.

Sessions are 50 minutes in length. Charge for each session (regardless of number in attendance) is $95.00. Payment is expected at the end of the session and may be made by check, cash or credit card.

HIPAA guidelines, with more details about federal laws and patient rights/responsibilities, are available upon request.

Please do not make an appointment unless you intend to keep it. If you cancel, the appointment will be charged in full. Thank you!

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I agree to the policies and requirements*

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Answers to the questions marked with an asterisk (*) are mandatory.

First Name*

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Last Name*

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Address

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State

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Date of Birth*

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Phone*

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Cell Phone

Best place for us to leave a message*

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Email (if you request email communication, be sure to check your spam box for our emails)*

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Emergency Contact*

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Emergency Contact Phone*

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Emergency Contact Relationship*

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How did you hear about Dr. Hurd?*

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Employment History*

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Education History*

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Why are you seeking therapy?*

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Why did you decide to seek help now?*

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How has this problem affected your daily functioning?*

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How has this problem affected your family?*

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How has this problem affected your social functioning?*

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Relationship Status

Have you been married? No Yes

How many children do you have, if any, and what are their first names and ages? Please list stepchildren as well.

Are any of them living with you?

Your religious background (if any):

What individual(s) in your life provide you with the greatest source of social/emotional support?

Medical History, and any present medical conditions

Current primary care physician, phone number and location:

Date of Last Exam?

Please list any psychiatric medications you are currently taking:*

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Please list any psychiatric medications you've taken in the past:

Please list other medications you currently take, and the reason for taking:

Are you allergic to any medications? If so, please provide details.

How many times per week do you use alcohol, and in what quantity?

Please describe your past and/or present use of alcohol and/or recreational drugs (marijuana, cocaine, etc.):

Have you ever been hospitalized for psychiatric reasons? No Yes

If yes, please list when and where:

Does anyone in your family have a history of mental health problems, either in your opinion or by diagnosis from a mental health professional/physician?

Have you ever, or are currently, having any thoughts of suicide, even just in passing?

Have you ever attempted to physically harm yourself, or come close to doing so? No Yes

If yes, in what way, and when:

Have you ever attempted to physically harm another, or come close to doing so? No Yes

If yes, in what way and when::

Have you ever experienced any type of abuse from a parent, spouse, partner or anybody else? (physical, sexual, emotional)? No Yes

Have you experienced any past traumas (e.g., major accidents, death of loved one, natural disasters)? No Yes

If yes, please describe:

Are you having any problems with your current eating patterns or appetite? No Yes

If yes, please describe:

How many times per week do you exercise?

What types of exercise do you do?

Is there any additional information you'd like to share? (Remember: Your answers on this form are totally confidential unless you agree otherwise.)

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