CONFIDENTIAL 〰️ CONFIDENTIAL 〰️ CONFIDENTIAL 〰️ Clinical HistoryIf you are filling out this history for a minor, please note that while it says "you," it refers to the minor. Name * First Name Last Name Email * Cellphone * Country (###) ### #### Address * Age * Race Sex * Man Woman Intersex Gender * Sexual Orientation What is the highest level of education you have obtained? What is your marital status? * Do you follow any spiritual or religious practices? * Are you currently employed? If so, what do you do? * Reason for seeking psychological treatment * Do you have any mental health diagnoses? If so, please list them all. * Have you previously undergone psychological or psychiatric treatment? * Have you ever been hospitalized in a psychiatric facility for a psychological emergency? If so, please provide the approximate date(s) and the reason for hospitalization. * Do you have any physical health diagnoses? If so, please list them. * Please list all medications you are currently taking and the condition they are prescribed for. * Please list all mental and physical health diagnoses of your biological family members (parents, siblings, children, grandparents). For example: Father: Hypertension; Mother: Bipolar disorder... etc. * Do you use any legal or illegal substances? If so, please specify the type and frequency (e.g., alcohol, twice a week; marijuana, daily, etc.). * Do you have a support network? Please list the members of your support network along with their phone numbers. These contacts will be used as emergency contacts. What are your strengths or the reasons you believe it is worth continuing to work toward improving your life? * What goal are you seeking to achieve with this treatment? * Do you have health insurance? If so, which one? Informed Consent: Duration: Typical sessions last 45–60 minutes. Voluntariness: Therapy is voluntary and may be discontinued at any time. Payment: Insurance co-pays are due before or on the day of the session. Out-of-pocket clients must prepay to confirm their session: $250 for intake and $200 for psychotherapy sessions. Confidentiality: Sessions are confidential unless there is a risk of harm to self or others. This includes the disclosure of abuse toward minors, the elderly, or vulnerable individuals, which may require mandatory reporting as per state and federal law. Results: Client is responsible for how insights are applied. Medications: Therapy does not replace medication. Psychologist does not prescribe. Sessions: Session count depends on diagnosis, goals, and treatment plan. Health Insurance: Some commercial plans accepted in Florida. Others must pay directly. Crisis: In emergencies, contact: 211 Helpline (Florida): Dial 211 Suicide Lifeline: 1-800-273-8255 Crisis Text Line: Text "HOME" to 741741 Call 911 Rescheduling: Changes with less than 24 hours’ notice = $75 late reschedule / no-show fee. Punctuality: Sessions begin at scheduled time. Language: Sessions available in English or Spanish. Platform: Services via telepsychology. Requires secure device, internet, and privacy. Payment: Accepted via card. Residency: By agreeing, you confirm Florida or Puerto Rico residency. Legal Scope: No legal reports, disability evaluations, or court testimony are provided. If court involvement is required, a $300/hr fee applies for preparation and participation. Financial Responsibility: Client must pay if insurance denies or does not cover. Insurance Release Authorization: I authorize the release of any necessary information (ROI), including clinical notes and records, to my insurance company for the purposes of treatment authorization, care coordination, and/or reimbursement. Referrals: If dissatisfied or non-compliant, you may be referred elsewhere. Telehealth Consent: You consent to therapy via telepsychology and may withdraw anytime. Scope of Telepsychology: If not clinically appropriate, you may be referred to in-person care. Electronic Communication: Email/text are not fully secure. Use only for admin/scheduling. Card: By providing your card information, you authorize charges for copays, deductibles, missed sessions, or other approved fees. Provider Discretion: Services may end if terms are violated or needs fall outside scope. Availability: No emergency services are provided. Messages are answered during business hours only and strictly for scheduling purposes. A valid debit or credit card must be kept on file for billing purposes. Card: By providing your card information, you authorize charges for copays, deductibles, missed sessions, or other approved fees. * By checking this box, I acknowledge that I have read and understood the information above. I consent to services and understand that this action serves as my electronic signature. I agree Thanks!