Dalia Intake Form Dalia Intake Form – Adults Step 1 of 4 25% Intake FormDate(Required) MM slash DD slash YYYY Referred by Name(Required) First Last AddressAddress(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell(Required)Email(Required) Personal InformationDate of birth(Required) MM slash DD slash YYYY Relationship status(Required) Social security # or Driver License # Current Occupation Employer Therapy InformationPrevious therapy(Required) Yes No When For how long? The Issues you would like to discuss with me:(Required)ConfidentialityYour records are confidential and no information contained in here will be released to anyone without my signed consent. The law releases psychotherapists from confidentiality only in cases where a client is in danger to self or others, in cases where elder or child abuse is suspected and when the court subpoenas records.Payments & Cancellation PolicyMy office cancellation policy requires at least 24 hours’ notice prior to your appointment. When canceling a session within less than 24 hours without notice, you will be responsible to pay for the full session fee since this time was reserved especially for you. Your Initials(Required) Notice of privacy practices (HIPAA) This notice describes how medical information about you may be used and disclosed and how you can get access to this information.This Notice of Privacy Practices describes how I protect your personal health information, tells when I can use and disclose your clinical information, and explains certain rights you have regarding this information. I am providing you with this notice in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and will comply with the terms as stated. I will obey the rules of this notices as long as it is in effect. You can get a copy from me at any time. As the law requires, I will ask you to sign a form indicating that you have read and understood this notice.Disclosure of Your Personal Health InformationI protect your personal health information from any inappropriate use and disclosure. The information obtained in the course of providing services to you and is related to your medical records, psychotherapy visits, and payment information. It is likely to include your history, reasons you came for psychotherapy, diagnose and progress notes I make. I will not disclose any personal health information without your written authorization, unless such disclosure is permitted or required by law.I need your permission to disclose information on an authorization form.You may revoke your discloser authorization at any time in writing.How your protected health information can be used and shared Your health information can be shared with other health care providers or another party only with your authorization for the purpose of advancing your treatment. I will disclose only the necessary information for the benefit of your treatment.Treatment and Care Management In order to provide care to you I have to obtain information from you about your background, condition and any relevant issues. Therefore you must sign the Consent form before I begin to treat you.Payment I can use your information to bill you. At your request I can send information to your insurance, or another party so I can be paid for the treatments I provide to you. Right to Inspect and Copy.You have the right to request a copy your personal health information. The request should describe the information you want to review. In limited circumstances, you may not be able to review or copy certain information. These include psychotherapy notes, or information collected for a claim or legal proceeding. If I determine that reviewing your records may cause harm to you or others or would negatively affect your treatment, I may deny access to your records. I may charge you a reasonable fee for the service of collecting and coping the data.Right to an Accounting of Disclosures.You have the right to receive a list of accounting disclosures of payments you made. Your request should specify the time period for which you want this list, which can be no longer than 3 years.For questions or problemsIf you need more information or have questions about the privacy practices described above, please speak to me. If you have a problem with the way your health information has been handled, or if you believe your privacy rights have been violated, contact me. You have the right to file a complaint with me and with the Secretary of the Department of Health and Human Services. Your Initials(Required) Informed Consent for PsychotherapyInformed Consent for Psychotherapy Welcome to Holistic Psychotherapy Center! Please read important information regarding my practice policies:APPOINTMENTS: Each session is 50 minutes long. Extended sessions can be scheduled at your request.In-person and telehealth sessions are available for your convenience. FEES: My fee is $250 per session payable at the end of each session. There is an additional fee in cases where you request a report and/or any additional services.Payment may be made by cash, check, CC (except American express), Venmo or Zelle.CANCELLATION & RESCHEDULING POLICY: Your appointments are reserved especially for you. I understand that sometimes schedule adjustments are necessary. I request at least 24 hours’ notice for cancellation or rescheduling appointments. In cases when you cancel or miss a session with less than 24 hours’ notice, you will be responsible to pay the full amount of the session missed. Please understand that when you change your appointment without enough notice, I miss the opportunity to fill this appointment time to someone else who would like to come in. CONFIDENTIALITY AND EXCEPTIONS TO CONFIDENTIALITY: All information disclosed within your sessions is confidential and may not be revealed to anyone without your written consent except where disclosure is required by law.Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect, where a client presents a danger to self, to others, to property, or is gravely disabled, or when a client’s family members communicates to me as your psychotherapist that the client presents a danger to others or self.In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. INSURANCE BILLING: I don’t provide direct insurance billing. I can gladly provide you a super-bill at the end of each month that you will submit to your insurance company for reimbursement. You can check with your medical insurance plan your out network coverage for Mental Health services.AUTHORIZATION TO RELEASE INFORMATION: There are times when you may want me to communicate with a third party such as a doctor or a family member for overall treatment progress. In this case you must complete and sign an Authorization to Release Information form. If you are in family or couples therapy, it must be signed by all adult parties who are part of the treatment.California law requires that counseling records be maintained for 7 years from the end of therapy and after that time they can be destroyed.TREATMENT FOR A MINOR: I require the consent of both parents/legal guardians prior to providing any services for a minor child under the age of 18.WAYS TO REACH ME: I don’t take direct calls by you but you can always leave me a message in the following ways:By phone at 818-501-8029By text at 818-665-2121By Email firstname.lastname@example.orgI respond as soon as possible within 24 hours.In case of an emergency please go to your local emergency room or call 911.I am committed to helping you with your specific concerns and challenges providing evaluation, a road map for your treatment plan and work collaboratively towards your wellness goals. I strive to honor the uniqueness of each person I work with and provide unwavering support and the highest level of care.CLIENT’S SIGNED STATEMENT:By signing below I acknowledge that I have read, understood and agreed to the terms described in this documentClient's Name (print)(Required) Signature(Required)Date(Required) MM slash DD slash YYYY Psychotherapist’s Name (print) Dalia Kenig, M.A., LMFT Signature Dalia Kenig, M.A., LMFT I,(Required) authorize Dalia Kenig, M.A., LMFT at IPEC Therapy Inc., AKA Holistic Psychotherapy Center, to charge my credit card specified below for all scheduled psychotherapy services, for all other services and for all agreed fees. Billing Address(Required) Phone(Required)City, State, Zip(Required) Email(Required) Credit Card(Required) DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name Product Name Price: Your Initials(Required)CAPTCHACommentsThis field is for validation purposes and should be left unchanged.