Intake Form Examples
Below are direct examples of the forms you will sign to become a client. If you have any questions, please email us from the link at the top of this page.
Emergency Contact
As a mental health provider, it is necessary that we have an emergency contact on file so that in the event of an emergency where we have significant concern for your wellbeing, we are able to contact someone before/instead of calling the police for a wellness check. By giving your permission for us to contact this person under the following conditions, you understand we are working together WITH you to help keep you safe, following our legal requirements as mandated reporters, and ultimately doing our best to navigate very difficult situations with as much tact and care as possible. Our commitment to you is to 1) Always attempt to make contact with you before reaching out to anyone else; 2) Notify you we intend to contact your emergency person (except in rare circumstances where doing so would like increase your risk of harm to self or others); and 3) Include you in whatever communication possible, as this is your treatment and we do not wish to exclude you from any discussion about your care.
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By signing, I consent to Grow Counseling Inc sharing limited relevant information my therapist judges to be pertinent with my emergency contact, ONLY in the event of an emergency or a situation where my therapist is gravely concerned for the ongoing safety of myself or others. I understand my therapist will only share this information if they have SIGNIFICANT concern for my overall health and wellness. I understand my therapist will use their best professional judgment, may consult with other experts, and will do their utmost to protect my privacy however possible if they have significant concern for my wellbeing.
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This is a Paragraph. Click on "Edit Text" or double click on the text box to start editing the content and make sure to add any relevant details or information that you want to share with your visitors.
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This is a Paragraph. Click on "Edit Text" or double click on the text box to start editing the content and make sure to add any relevant details or information that you want to share with your visitors.
List Title
This is a Paragraph. Click on "Edit Text" or double click on the text box to start editing the content and make sure to add any relevant details or information that you want to share with your visitors.