Intake Info - Courageous Decisions Coaching

Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Birthdate *

Current Age *

Social Security #

(if using insurance)

Occupation

Employer (or school name)

Unmarried
Married
Separated
Divorced

Spouse/Partner Name

Spouse/Partner Age

In case of emergency, notify *

Emergency Contact Phone *

______________________________________________________________________________________

Other Referral Source

Would you like to receive news or notifications from Kevin occasionally? *

Email
U.S. Mail
None

List people living in your home besides you:

List people living in your home besides you: (copy)

List people living in your home besides you: (copy) (copy)

List people living in your home besides you: (copy) (copy) (copy)

List people living in your home besides you: (copy) (copy) (copy) (copy)

List people living in your home besides you: (copy) (copy) (copy) (copy) (copy)

__________________________________________________________________________________________________________

Briefly describe your reasons for seeking therapy/coaching: *

Have you ever participated in therapy or counseling or coaching of any kind? *

Have you ever attempted suicide?

Do you presently have suicidal thoughts? *

__________________________________________________________________________________________________________

Consent Area (please check each box below to indicate you've read the corresponding item): *

FINANCIAL TERMS: Psychotherapy sessions are typically 50 minutes in length and are billed at a rate of $200.00 per session.
CONFIDENTIALITY: All information between therapist and client is held strictly confidential unless: 1. You authorize release of information with your signature (or parent/guardian) 2. You present a physical danger to yourself 3. You present a danger to others 4. Child or elder abuse is suspected In the latter two cases, I am required by law to inform potential victims and legal authorities so that protective measures can be taken.
CANCELLATIONS / MISSED APPOINTMENTS: When we decide to work together it means that I am setting aside time exclusively to meet with you. I will not accept phone calls during sessions (unless of course there is an emergency). I will also do everything in my ability to be emotionally and intellectually present. In return I expect you to make therapy a priority, too. This means that you will attempt to be as honest with me as you can, you will arrive promptly for our sessions, you will not drink alcohol or take any illegal drugs prior to our sessions, and you will provide me with at least 24 hours to cancel an appointment. If an appointment is missed or cancelled with less than 24-hour notice, you agree to pay the full fee for the missed appointment.
EMERGENCIES: If you are in imminent danger call 911 or your nearest police department or emergency room. I will respond to phone and text messages during business, usually within a 4-hour window or the next business day. Voice messages may be left at 310-530-7750. Text messages may be left for me at 424-262-1776.
TREATMENT PHILOSOPHY: The purpose of psychotherapy is to help you cope more effectively with your life. Hopefully your situation will improve during the course of therapy, but that doesn’t mean the benefit comes immediately and without pain. Your situation often may get worse before it gets better. Sometimes it is necessary to deconstruct unhealthy patterns in your life and in your relationships before you can reconstruct healthier patterns. My particular style of therapy is direct and “no nonsense.” While I have proper education, training, and experience, it doesn’t mean my style may fit for you. (For example, penicillin can save one person’s life and kill the next if he or she is allergic.) I will be responsible for providing you with the most helpful therapeutic experience during our sessions, and ultimately you are responsible for your therapy. If you don’t think I am helping you, then please let me know as soon as possible. We will discuss what is missing and see if I can meet your needs, if not, I will gladly try to help you find a therapist who may be a better fit.
CONSENT FOR TREATMENT: “I hereby authorize and request Kevin Bergen, MFT to carry out psychological examinations, treatments, and/or diagnostic procedures which now or during the course of my care as a client are appropriate. I understand that the purpose of these procedures will be explained to me upon my request. I also understand that while the course of my treatment is designed to be helpful, it may at times be difficult and uncomfortable.”

__________________________________________________________________________________________________________

Phone