A Welcome Letter to My New Client

A WELCOME LETTER TO MY NEW CLIENT

Dear New Client:

Welcome! I have provided the information in this New Client Welcome Packet me help you better understand the services offered by my practice and to help you benefit more rapidly and completely from our services. Please read and sign the enclosed “Therapist Disclosure and Client Responsibilities” and return it to your therapist at your next session. If you have any questions, I will address them at your next appointment. This disclosure is meant to foster your achieving your goals for self-growth by accelerating your progress through therapy by providing information, which will be helpful in gaining the greatest benefit from your therapy in the least amount of time. Please feel free to discuss any of the information provided at the time of your next appointment. Please also complete the

At Multicultural CBT-DBT/ The Flying Psychotherapist. I offer individual adult, and family psychotherapy and groups as well as assessment services to help individuals heal emotionally and regain normal functioning. In addition, I offer services to foster an individual’s personal growth in order to reach their full potential, emotionally, and in the family and business life.

Cordially,

Suhadee Henriquez, LCSW, ACT

Fellow, Academy of Cognitive Therapy

Multicultural CBT-DBT, LLC/ The Flying Psychotherapist

774-7CBTDBT

774-722-8328

866-443-6781 (FAX)

Date:______

Name of Client: ______

ADULT QUESTIONNAIRE

This form will assist your therapist in knowing about you and will be kept confidential. Please complete all seven (7) pages.

Print clearly.

CLIENT DEMOGRAPHICS

Client Name:______

Email: ______

Telephone Number: ______

Home Address: ______

Birth date: ______/______/______Age:______Gender:Female Male

Referred here From: ______

PRESENTING PROBLEM

Describe the problemsyou are having and when they began:

______

What has contributed to this difficulty? ______

______

MEDICAL HISTORY

List allergies, serious illnesses, surgeries, injuries, hospitalizations: ______

______

List both prescription and over-the-counter medications presently used for physical conditions:

______

My over-all general health is: ___Excellent ___Good ___Fair ___Poor

What physical illnesses run in your family? ______
What is the name of your Doctor/Pediatrician? ______

EDUCATIONAL HISTORY

What is the highest grade you have completed? ______
Do you have any problems in school? YESNO If yes, please explain:

______

Have you ever repeated or skipped a grade? YESNO Which one? ______

Have you ever dropped out, been expelled, or been suspended? Which one? ______

What happened?

______

How has your attendance been? ___Excellent ___Good ___Fair ___Poor

What are your grades like? ______Have they changed a lot? YES NO

Do you have learning difficulties or attend special classes? YESNO

Have you ever had psychological testing?YESNO

What are your extra-curricular activities? ______

______

OCCUPATION

Where do you work? ______What do you do?

LEGAL HISTORY (in regards to child or any family member)

Have you ever been involved with the legal system (criminal, divorce, custody, civil, etc.)? YES NO If so, in what way?

______

Are you currently involved with the legal system (criminal, divorce, custody, civil, etc.)? YES NO If so, in what way?

______

Do you have any criminal or civil cases pending? YESNO

Do you currently have a probation/parole officer? YESNO If so, who? ______

Do you anticipate any involvement with the legal system in the future? YESNO

TREATMENT HISTORY

Have you been in therapy before?YESNOIf so, with whom? ______
What was the primary issue? ______

When? ______For how long? ______What was the outcome?

______

Have you ever been hospitalized for emotional problems or for alcohol/drug treatment? YESNO

If so when? ______Where? ______What was the outcome?

What medications have you taken in the past for emotional or mental problems?

______

What medications are you currently taking for emotional or mental problems? ______

Is there a history of mental illness in your family? If so, please explain______

______

SOCIAL HISTORY

What are your major strengths?

______

What are your major weaknesses? ______

______

From whom do you get emotional support? ______
Do you have friends? YESNO
How do you get along with those friends? ______
Has there been a change in your circle of friends lately?YESNO
Do your friends tend to get into trouble?YESNO
Do you belong to a gang?YESNO
Do any of your friends belong to a gang?YESNO
What have been the losses, changes, crises, and transitions in your life? ______

Do you have a belief system (cultural, moral, spiritual, religious, etc.) which influences your life? Please explain:

______

Is there anything about your lifestyle (or the family’s) that would be helpful for your counselor to know?

______

FAMILY HISTORY

ABOUT YOUR HOUSEHOLD

Name Age Relationship to You How do you get along?

______

Important people in your life (immediate family/relatives/significant others)

Name Age Relationship to You

______

Do you live with your parents? YES NO Have you ever lived away from your parents? YES NO

Under what circumstances? ______

Do you have any brothers/sisters, step-brothers/sisters, or half-brothers/sisters who do not live with you? YES NO

Your experiences while growing up can affect your life. What experiences and events (discipline, favoritism, trauma, affection, lack of attention, etc.) have been important in your life? ______

______

Please list your present and past boyfriend(s)/girlfriend(s).

First Name Time Together Reason for Ending Relationship

______

PHYSICAL DEVELOPMENT

Please complete/check the following:

_____Height_____Underarm hair

_____Weight_____Menstruation (female)

_____Build (light, average, heavy)_____Voice change (male)

_____Breast development (female)_____Beard (male)

_____Genital hair_____Acne

SEXUAL HISTORY

Sex Education:_____Home; _____School; _____Friends
Are you currently sexually active?YESNO Single Partner ______Multiple Partners ______

Same Sex Partner ______Both Sex Partners ______

Do you use Condoms? YES NO Do you use Birth Control? YES NO
Have you ever had a STD (Sexually Transmitted Disease)? YES NO

If so what? ______

Have you ever been sexually abused? YES NO If yes, by whom and for what length of time?

______

Has anyone ever touched you or talked to you sexually in a way that made you uncomfortable? YES NO

CONCERNS

For you or any of the above relationships (household, brothers/sisters, partners), have you or any of those persons ever experienced any of the following problems:

ConcernPerson(s) Who Experienced This

Mental Illness______

Depression______

Neglect______

Sexual Dysfunction______

Financial Difficulty______

Emotional Abuse______

Physical Abuse______

Sexual Abuse______

Alcohol Abuse______

Drug Abuse______

Other:______

POSSIBLE ISSUES

SUBSTANCE ABUSE Do you use drugs? Regularly? Occasionally? How does your usage affect your life?

______

What drugs have you taken:

_____Depressants: Alcohol, Tranquilizers, Sleeping Pills, Inhalents

_____Stimulants: Cocaine, Crack, Crank, Speed, Diet Pills

_____Stimulants: Caffeine, Nicotine

_____Narcotics: Heroin, Codeine, Morphine

_____Hallucinogens: LSD/Acid, PCP, Peyote, Shrooms

_____Cannabis: Marijuana

_____Other:______

When did you first use? ______When did you last use? ______

SUICIDE/HOMICIDE

Have you ever had or do you have? Check all that apply.Past Now

Thoughts of hurting yourself?______

Thoughts of committing suicide?______

Plans to commit suicide?______

Attempts to commit suicide?______

Threats to commit suicide?______

Thoughts of harming someone?______

Plans to harm someone?______

Attempts to harm someone?______

Threats to harm someone?______

Actually harmed someone?______

DEPRESSION

Have you ever or do you now have? Check all that apply. Past Now

Inability to sleep or sleeping longer?______

Increased or decreased appetite?______

Tearfulness or feelings of despair?______

Lack of energy or feelings of fatigue?______

Preoccupation with life events?______

Decreased contact with others?______

Feelings of depression? ______

Decreased interest in pleasurable activities ______

Is there anything else that may be helpful for your counselor to know that we have not asked?

______

67 Irving Place South, 2nd Floor, New York NY, 10003 | 774.772.8328 |866-443-6781 (FAX)

Multicultural CBT-DBT, LLC

Child Checklist of Characteristics

Please check all that apply.

Accident prone
Affectionate
Aggressive
Argues, “talks back,” smart-alecky, defiant
Assaults
Bathroom language
Bigoted
Bossy to others
Breaks rules
Breaks the law
Bullied by others
Bullies/ intimidates, teases, inflicts pain on others
Cheats
Clowns around
Competition
Complains
Complains of feeling sick
Compliant
Concern for others
Conflicts at school
Conflicts at home with parents over rule breaking, money, chores,choices
Conflicts with friends
Conflicts with police
Cries easily, feelings are easily hurt
Cruel to animals
Dares others
Dawdles, procrastinates, wastes time
Daydreams
Defiant
Dependent, immature
Destructive
Developmental delays
Difficulties with parent’s paramour/new marriage
Disobedient, uncooperative, refuses, noncompliant
Disrupts family activities
Distractible, inattentive, poor concentration, daydreams
Dropping out of school
Drug or alcohol use
Drug sales
Eating issues, poor manners, over/under eats, refuses
Exercise problems
Extracurricular activities interfere with academics
Failure in school
Fantasy life
Fearful
Feelings are easily hurt
Fidgety
Fighting, hitting, violent, aggressive, hostile, threatens
Finger sucking
Fire starting
Fire setting
Friendly, outgoing, social
Hair chewing, pulling
Head banging
Hitting
Hostile
Hyperactive
Hypochondriac, always complains of feeling sick
Imaginary playmates, fantasy
Immature, “clowns around,” has only younger playmates
Inappropriate sexual behaviors
Inattentive
Independent
Inflicts pain on others
Insults others
Interrupts, talks out, yells
Intimidated by others
Intimidates others
Intolerant
Irritability
Isolates
Lacks organization, unprepared
Lacks respect for authority, insults, dares, provokes
Learning disability
Legal difficulties, truancy, loitering, vandalism, drinking
Lethargic
Likes to be alone, withdraws, isolates
Loitering
Loss of friends
Low-frustration tolerance, irritability
Lying
Manipulates
Masturbation
Mental retardation
Moody
Mute – refuses to speak
Nail biting
Name calling
Needs high supervision at home overplay/chores/schedule
Negativism
Nervous
New school
Nightmares
Noisy
Noncompliant
Obedient
Obesity
Only younger playmates
Oppositional, resists, refuses, does not comply, negativism
Outgoing
Out-of- seat behaviors
Overactive, restless, hyperactive, restlessness, fidgety
Picks on others
Poor concentration
Pouts
Prejudiced, bigoted, insulting, name calling, intolerant
Procrastinates
Provokes others
Rages
Recent move, new school, loss of friends
Refuses
Relationships with friends are poor
Relationships with siblings –competition, fights, teasing/provoking
Relationships with teachers poor
Resists
Responsible
Restless
Rocking motion/behavior
Repetitive movements
Runs away
Sad, unhappy
School avoiding
Self-harming behaviors—biting, hitting self, scratching
Sexual preoccupation, inappropriate sexual behaviors
Sexually active
Shy, timid
Slow moving
Slow responding
Smart-alecky
Smoking
Social
Speech difficulties
Stealing
Stubborn
Suicide talk or attempt
Swearing, blasphemes, bathroom language, fowl language
Talks back
Teased, picked on, victimized, bullied
Teases others
Temper-tantrums, rages
Threatens
Thumb sucking, finger-sucking
Tics – involuntary rapid movements, noises or word productions
Timid
Truancy, school avoiding
Uncooperative
Uncoordinated, accident-prone
Under-active, slow-moving
Unhappy
Unprepared
Vandalism
Violent
Wastes time
Wetting/soiling of bed or clothes
Withdraws
Yells

67 Irving Place South, 2nd Floor, New York NY, 10003 | 774.772.8328 |866-443-6781 (FAX)

Multicultural CBT-DBT, LLC

PLEASE SIGN BELOW TO INDICATE THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT:

CLIENT: ______DATE: ______

CLIENT NAME: ______

Informed Consent for E-mail/Electronic Communication

Notice to Clients: Use of e-mail/electronic communications between clients and their therapists has risks regarding protection of your private health care information. Some examples include:

E-mails/electronic communication can be intercepted by someone who is not the intended recipient.

Intercepted e-mails/electronic communication can be stored and printed by the unauthorized recipient.

Your identity can be determined from knowing your e-mails/electronic communication address.

E-mails/electronic communication are easily, and sometimes, accidentally, forwarded to unintended recipients

E-mails/electronic communication can transport computer viruses and other malicious software.

Receipt of e-mails/electronic communication sometimes are not noticed, not responded to, in a timely manner.

Detailed identifying information, diagnoses and treatment information about you should not be put in the subject line or body of an e-mails/electronic communication, nor be transmitted as an attachment to an e-mail

E-mails/electronic communication should never be used to communicate emergency, urgent or other time-sensitive information.

If you choose to use e-mails/electronic communication as a way to communicate with your therapist, please read and sign below.

* I have read and understand the information provided regarding -mails/electronic communication. I have had my questions regarding this answered to my satisfaction.

* I understand that Counseling Services is required by Federal and State Law to try to protect my private health care information, which is the reason I am being informed of the risks involved with e-mails/electronic communication.

* I understand that I am not required to participate in e-mail and electronic communication, but if I do consent, I may withdraw this consent at any time by notifying my therapist.

I give my informed consent to participate in e-mail and electronic communication with Multicultural CBT-DBT.

______

Signature Date

______

Witness Date

HIPPA Notice of Privacy Practice

By signing this form, you acknowledge receipt of the Notice of Privacy Practices from the Multicultural CBT-DBT. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. The Notice of Privacy Practices is subject to change. If the Notice is changed, you may obtain a revised copy by visiting our website at or on request.

I acknowledge receipt of the Notice of Privacy Practices Multicultural CBT-DBT.

Signature: ______Date: ______
(Client / Parent / Guardian)

Signature: ______Date: ______

(MCCBT Client Name)

Billing and Cancellation Policy

Psychotherapy Services Agreement with Suhadee Henriquez.LCSW, ACT

Notice of Policies and Practices to Protect the Privacy of your Health Information

This document contains important information about our professional services and business policies. It also contains information about our policies and practices to protect the privacy of your health information. Please read it carefully and discuss any questions you may have with me. When you sign this document, you will be stating that I provided you with this information and it will represent an agreement between us.

PSYCHOTHERAPY SERVICES

Psychotherapy varies depending on the therapist, the client, and the client’s life situation and goals. There are many different methods I may use to deal with your particular situations and goals. In order for therapy to have the best outcome, you will have to invest energy in the process and work actively on things we talk about both during and between our sessions.

Psychotherapy can have benefits and risks. The risks may include experiencing uncomfortable feelings like sadness, guilt, anger, anxiety or frustration when discussing aspects of your life. Psychotherapy has been shown to have benefits that can include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and significant reductions in feelings of distress. However, it is impossible to predict or guarantee what you will experience.

Our first few sessions will involve an evaluation of your situation and needs and we will discuss goals you want to work towards. During this time, we can both decide if I am the best person to provide the services you need. Psychotherapy can involve a significant investment of time, energy and money, so it is important that you select a therapist you are comfortable working with. If at any time you have questions about some aspect of our work together, please discuss them with me. If you decide that you do not want to continue in therapy with me, please tell me. If you want me to help you find another therapist or other appropriate resources, I will do so.

CONFIDENTIALITY

Your mental health information is confidential; however therapists are mandated reporters which means that in certain circumstances, I am required by law to release information without your consent. These situations are described below. Please read these situations and feel free to ask any questions about them.

If you make a specific threat to harm yourself or someone else (and the risk of danger is deemed imminent), I must take appropriate steps to protect you or warn the appropriate parties.
If I suspect you have physically or sexually abused or neglected a child or vulnerable adult, I must make a report to the proper authorities. This includes some cases of domestic abuse when a child is exposed to weaponry or is physically threatened and/or used as a weapon.
If you are pregnant and using a controlled substance, such as heroin, cocaine, phencyclidine, methamphetamine, or their derivatives.
When there is a court order to release your records to the legal authorities.

Payment is requested at time of service. I accept all credit cards, cash and check payable to Suhadee Henriquez.

Cancellations and Missed Session Fees. We require at least 24 hours advance notice if you are not able to attend your scheduled appointment.

Sessions canceled with less than 24 hours’ notice will be charged the full session fee.

Insurance. I do not accept insurance. However that does not necessarily mean you cannot get some reimbursement from your insurance. If you intend to use your insurance, we suggest that you find out the reimbursement rate for mental health services for an “out of network provider.” This will give you an idea of how much reimbursement you can expect. Please be aware that since we bill clients directly at the time of the session, you will be responsible for providing payment to us and then collecting any reimbursement offered through your insurance.

Unpaid bills. If you default on your payment, you may be sent up to three notices requesting payment. If there is no good faith attempt to pay off the balance of your bill, please be advised that the bill may be sent to a collections agency. This may incur extra charges as well as negatively impact your confidentiality, privacy, and credit history.