Name: First ___________________________________ MI. ____ Last ____________________
SS# __________________________________ DOB _______________________ Age _______
Male ___ Female ___ Married ___ Single ___ Separated ___ Divorced ___ Widowed ___
Street Address _________________________________ City ______________ ZIP _________
Home Phone _______________ Work Phone _______________ Cell Phone ________________
Student? Y N Full-Time__ Part-Time __ Are You Employed Y__ N__ If Yes: F-T __ PT ___
Employer Street Address ________________________ City ________________ ZIP ________
Name of Policy Holder Last, First MI _______________________________________________
Primary Insurance Company ___________________________ Ins. Co. Phone # _____________
Policy Holder SS# _______________ Policy Holder DOB _____________
Subscriber ID _____________________________________ Group # ____________________
If Client is a Minor
Mother’s Name: _____________________________________ Phone# ____________________
Street Address: ___________________ City ______________ State _____________ Zip ______
Mothers Employer _________________________________ Phone# _____________________
Fathers Name _____________________________________ Phone# ______________________
Street Address _____________________ City _________________ State _______ Zip _______
Fathers Employer _______________________________________ Phone# _________________
Referred by: PCP: ___ Psychiatrist ___ Counselor ___ Friend ___ Internet ___ Ad ___ Other _
Assignment and release: I hereby authorize the benefits to be paid directly to the counselor. I agree that I am financially responsible for non-covered services. I authorize the counselor to release any information required to process my claims.
Signature: ______________________________________________ Date: ________________
In case of emergency, name of nearest relative or friend we should contact:
Name _________________________________ Address ________________________________
Phone# ___________________ Email address ________________________________________
Counseling Services of Conroe
Please provide a brief history for us to best assist you in meeting your therapeutic goals.
Education (check all that apply):
GED ___ HS Graduate ___ 2 year AA/AAS ___ 4 year BA/BS ___ Masters & up ___
Have you served in the military? Y N Which Branch? _____________ Discharge date?______
Family History (Please circle response):
Who raised you? Biological Mother Y N Stepmother Y N Grandparent Y N Other Y N
Biological Father Y N Stepfather Y N Grandfather Y N Other Y N
Number of siblings? Full Blood _____ Half ______ Step ______
Have you received assistance from any of the following? Psychiatrist Psychologist Therapist
LCSW Inpatient/Outpatient Hospital Drug Abuse Treatment Self Help Support Groups
Please explain each item circled: ___________________________________________________
Substance Abuse History:
Circle the alcohol or drugs you have used/abused or currently take without a prescription.
Alcohol Marijuana Cocaine (crack/powder) Methamphetamine Heroin Ecstasy Opiates
Synthetic marijuana (K2, Spice, Fake Bake) PCP Hallucinogens Inhalants Steroid Bath Salt
Other prescription drugs-antidepressants Non prescription drugs i.e. cough syrups, Sudafed
Does anyone in your family have an alcohol/drug problem? Y N If yes who? _____________
Medical/Mental Health History:
List medical/mental health diagnosis for which you are currently being treated:
Current Medications prescribed:
Family history of medical or mental health problems: ______________________________________________________________________________
Medical/Mental Health History:
Please circle symptoms/behaviors that are problematic for you.
Aggression Alcohol Dependence Anger Hallucinations Anxiety Avoiding People Depression Dizziness Drug Dependence Eating Disorder Phobias/Fear Fatigue Gambling Sexual Addiction Hopelessness Impulsivity Irritability Judgment Errors Loneliness Mood Memory Impairment Hyperactivity Panic Attacks Pornography Trembling Withdrawals Disruptive Thoughts Spending Problems Sexual Difficulties Sleeping Problems Worrying Suicidal Thoughts Disorganized Thoughts Social Problems Isolating
Explain how the above items impact your daily functioning:
Were there special or unusual circumstances that affected you in childhood? (i.e car accidents, domestic violence, trauma, natural disasters, significant loss of a loved one) Y N
Please explain any unusual events that have occurred in the last 12 months. ______________________________________________________________________________
What would you like to accomplish with counseling?
Counseling is a process in which you will grow, learn about yourself and the world around you such that stressors, substance abuse and other barriers might be removed. Cognitive Behavior Therapy and Solution Focused approaches help you gain these insights.
Thank you for selecting Counseling Services of Conroe. We wish to do our best in making this experience meaningful. Please read the pages thoroughly and ask questions for clarification as needed. The information provided will allow us to provide services that will be meaningful and appropriate for you.
Per Session $120 45-50 minutes
Phone Time $30 10 minutes
Other Fees (Prorated)
Court Testimony or deposition $500 per hour (2 hour min.)
Local travel $125 per hour (1 hour min)
Waiting/preparation for testimony $250 per hour
Records Review $125 per hour
Consultations and other services $125 per hour
Returned check fee $25 each item
*Sliding Scale fee available based on income
Changes and Cancellations:
At times, the unexpected occurs, like inclement weather or your child becomes ill. Your appointment is important though and your therapist is happy to accommodate you with a phone session so that you can care for your sick child or alleviate concerns about the weather. We can help you keep your scheduled appointment, provided that you are in a confidential location. Please keep in mind: most insurance plans will not pay for phone therapy. If you still must change or cancel your counseling appointment, please be aware of the following:
- Cancellations must be made no less than 24 hours before the scheduled appointment.
- We cannot accommodate cancellations made after hours or on holidays. If you have an appointment on Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment.
- Cancellations without the aforementioned notice will result in a fee of $30 that will be collected at your next appointment, or if payment information is on file, it will be debited from your credit card.
- After three no-shows/late cancellations, you will be referred out to another counselor for continuation of services.
- Additional services related to court preparation including correspondence with attorneys or other service providers via phone, email, or letter, documentation review and or documentation preparation are also billed at $250 per hour, at a two hour minimum.
Your signature below indicates that you have read this agreement and agree to its terms in its entirety.
Signature ___________________________________________ Date __________________