6829 Gravois Ave.                                                                                                                                      314-517-8383

St. Louis, MO  63116                                                                                                                                                                   

Thank you for taking a few moments to complete this form.  Feel free to ask any questions that come to mind.


Reason you are seeking services at this time:  _______________________________________



Client’s Name:  ________________________________________  Date of Birth:  ___________

Street:______________________________________ _City_______________ ZIP Code______

Home Phone ___________________    Other Phone _________________

Employer _________________________________________  Income __________________

Education (circle highest level completed) Grade School     High School     College   Grad School

Client’s Marital Status _____________________   Number of Children _________

Other Significant Persons in Client’s Life ________________________________________________


In an emergency contact (Name/Phone)_______________________________________________

Have you ever had a psychiatric hospitalization?_________________________________________

Any Ongoing Medical Problems (Describe)?___________________________________________

Please list any medication you are currently taking (any medication allergies?)-_______________


Any current legal issues? ________________________________________________________

Many insurance companies ask therapists to contact Physician to coordinate care.  Do you give permission for this?  Declineo   Agree o Name of Primary Care Physician _________________________

(Your written authorization is required if you would like your therapist to speak or share reports with any other person)

Name of Psychiatrist, Counselor, or other Health Care Professionals you are working with:_____


Have you been involved in therapy/counseling before?____________________________________

Scheduling:  Please call at least 24 hours in advance to cancel an appointment.  You may be charged for appointments not kept or canceled without 24 hours notice.

Crises:  If you feel an urgent need to talk between sessions, call me at 314-517-8383 (“51-STEVE”), and I will return the call as soon as possible.  If the emergency is life threatening, call Life Crisis Services Hot Line (647-4357), Behavioral Health Response(800-811-4760), or “911”.

Fees:  The standard fee is $90 per hour, usually collected during each appointment.  Special payment arrangements, such as a sliding fee scale, insurance reimbursement or delayed payment, may be negotiated with the therapist.

Privacy:  I will adhere to all state laws and ethical standards.  You can expect information from your counseling sessions to be kept confidential by me, unless: 1) You report information that a child appears to have been abused; 2) You express intent to kill or seriously injure yourself; 3) You express intent to kill, seriously injure, or commit a crime against someone else; or 4) You report unethical behavior by another therapist.  Information about your therapy may also be subpoenaed by a court of law, although our right to maintain client privilege (confidentiality) has been upheld by the Supreme Court.  Your case may also be discussed for the purposes of clinical consultation with other therapists.  You may also give me written authorization to discuss your case with any one else you choose.

A full Notice of Privacy Practices and Standards of Communication are posted in my waiting room and on my web site, or can be printed upon request.

Case Closing:  If there is no session or communication with the therapist for a period of 6 months, the case will be closed.  Therapy may later be resumed by mutual agreement.


I have read and understand the above.________________________________________     _________

                                                                                                  Client Signature                                  Date