Counseling For Your Mental Well Being

Client Intake Forms

Save time at the office and fill out client intake forms online before your appointment. Fill out the forms below and our team will email you a confirmation that we've received them.

Step 1 of 8

Appointment Policies, Fees, and Agreements
Acknowledgement of Appointment Policies, Fees, and Agreements*
1. All appointments are scheduled at the office or by telephone. In crisis situations, every attempt will be made to arrange an urgent care appointment, but it is best to schedule in advance. For prime time appointments we encourage you to schedule weeks in advance.
2. If you must cancel an appointment, a 24 hour notice is REQUIRED unless there is a MUTUALLY agreed upon situation. If such cancellation is not made, the charge for a missed session is $50.00.
3. Our office does not have an answering service. We apologize for any inconvenience that this may cause you. We will do our best after hours to collect messages; however, we are unable to guarantee immediate returns of emergency telephone calls, until the next business day. Therefore, in the case of an emergency, please go to the nearest hospital or call 911.
4. Self pay (not utilizing insurance) fees for services will vary and will be determined and communicated upon the first session for initial interview, assessment, and psychotherapy. Clients without insurance are expected to pay in full at the time of the service, unless other arrangements are made with this office.
5. There are fees for psychological testing/assessments, reports, letters/forms, school appearances, court reports and appearances, and additional services. Fees vary and will be agreed upon prior to the service. In addition, some paperwork will require an appointment to ensure accuracy of documentation.
6. Your insurance company is entitled to any medical or other information necessary to process your insurance claims. Your Signature on File is to be used on all insurance submissions. Your provider or their office staff may act as your agent in helping you obtain payment from your insurance company. The insurance payment is to go directly to your therapist. You authorize the use of this form on all insurance submissions. You permit a copy of this authorization to be used in place of the original.
7. For clients using insurance, your copay or coinsurance is due at the time of your appointment. If your insurance payment for the balance is not received within 60 days, or if the amount paid by your insurance is less than expected, you will be responsible for the total amount remaining.
8. For services rendered to a minor dependent, the PARENT WHO SIGNS THIS FORM is the one responsible for the balance.
9. There is a $30.00 fee for any returned checks. If a returned check is not rectified in a timely manner, you hereby give consent for this office to employ the State Attorney’s Office to collect on the outstanding debt. You understand that failure to make payment on a check and not making the outstanding check good in a timely manner is a crime, and this office does prosecute to the fullest extent by law.
10. If you fail to pay your account in a timely manner, you give consent for this office to employ another agency (i.e., attorney, or collection agency) to collect any outstanding debt. You understand that you will be responsible for any additional costs. You also understand that all necessary records will be released to the retained agency.
- I have read, understood and agreed to the Appointment Policies, Fees, and Agreements.
Name*
(Responsible Party)
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Today's Date*
MM slash DD slash YYYY
Signature*
Minor Consent
Check here if you are filling this form out on behalf of a minor.
Minor's Name
First Last
Minor's Date of Birth
MM slash DD slash YYYY
Minor's Signature

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Credit Card on File Agreement
Credit Card on File Acknowledgement*
At Triangle Resolutions, we require a credit card on file. This is a convenient method of payment for the portion that your insurance doesn’t cover, and for which you are liable.

Your credit card information is kept confidential and secure. Payments to your card are processed only after the claim has been filed and processed by your insurer.

I, the undersigned, authorize and request Triangle Resolutions to charge my credit card, indicated below, for balance due for services rendered. This authorization relates to all payments not covered by my insurance company for services rendered by Triangle Resolutions, including charges related to our Appointment Cancellation Agreement as noted below.
First Name Last Name
Appointment Cancellation Agreement
Appointment Cancellation Acknowledgement*
• It is my responsibility to notify Triangle Resolutions of any changes to the credit card on file associated with this agreement.
• This policy will remain in effect until I cancel this authorization. To cancel, I must give a 30 day notification to Triangle Resolutions in writing and with account in good standing
• To protect patient care, appointment availability, and our Therapist’s time, we require 24 hours notice in the event you need to reschedule your appointment
• A $50.00 cancellation fee will be charged to you and this fee cannot be billed to your insurance carrier
• Reminder calls for appointments are provided as a courtesy only.
• If I decline to have my credit/debit card on file, then a $50.00 deposit will be required.
• Additional appointments will not be scheduled if account is not in good standing.
First Name Last Name
Today's Date*
MM slash DD slash YYYY
Client Signature*
Parent of Minor / Guardian Advocate Name
First Last
Today's Date
MM slash DD slash YYYY
Parent of Minor / Guardian Advocate Signature

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Client Rights
Acknowledgment of Client Rights*
All individuals who apply for services, regardless of sex, race, age, color, creed, financial status or national origin are assured that their lawful rights as clients shall be guaranteed and protected.

1. To be provided a copy of our office’s Privacy Notice.
2. To be treated with respect and dignity.
3. To privacy for interview/counseling sessions.
4. To confidentiality
Exceptions:
(a) The court may request information about clients and/or treatment without client consent.
(b) By law, all suspected cases of child abuse/neglect must be reported.
(c) By law, all suspected cases of elderly abuse/neglect must be reported.
(d) By law, “Whenever a patient has declared an intention to harm other persons, such declaration may be disclosed.
(e) If client fails to make good on a bounced check within a reasonable amount of time, some confidentiality information may be released so that the State Attorney’s office can collect on the outstanding debt.
(f) If client fails to pay the balance of his account in full within a reasonable amount of time, some confidential information may be released so that collections of the fees may be pursued.
5. To refuse treatment.
6. To be informed of the client grievance procedure upon request.
7. To receive full information regarding treatment process.
First Name Last Name
Client Date of Birth*
MM slash DD slash YYYY
Today's Date*
MM slash DD slash YYYY
Client Signature*
Family/Significant Others Participation*
- I AGREE to have family/significant others participate, in the treatment process including the provision of information about the effects of medication.
- I DECLINE to have family/significant others participate, in the treatment process including the provision of information about the effects of medication.
Name of person allowed to participate in the treatment process:*
Signature of Family/Significant Other*
Parent of Minor / Guardian Advocate Name
First Last
Today's Date
MM slash DD slash YYYY
Parent of Minor / Guardian Advocate Signature

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Consent for Services / Treatment
Agreement to Consent for Services & Treatment*
I, the undersigned client of Triangle Resolutions and any Associates of Triangle Resolutions

I, the Undersigned, a (Parent of a minor, Guardian, Guardian advocate) of the above named client

Who is a client of this office and the subject of this authorization, hereby authorize the professional staff of the above stated agency to administer mental health and/or substance abuse services/treatment, which may include psychotherapy, clinical hypnosis, Clinical Brainspotting, psychoeducational services and/or emergency evaluations, EXCEPT Electroconvulsive treatment.

I have been informed that this consent can be revoked orally or in writing prior to or during the treatment period. I acknowledge that there have been no guarantees or assurances made to me as to the results of services/treatments rendered by Triangle Resolutions and any Associates or employees of Triangle Resolutions. I am aware that I am financially responsible for any costs incurred as the result of services/treatment rendered by this office and such costs may be adjusted based on my gross family income. I have read and fully understand the above Consent for Services/Treatment.
First Name Last Name
Date*
MM slash DD slash YYYY
Signature*
Parent of Minor / Guardian Advocate Name
First Last
Parent of Minor / Guardian Advocate Signature
Client Information
(If minor, use minor's information)
Name*
First Middle Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Sex*
Date of Birth*
MM slash DD slash YYYY
Marital Status*
Employer
Occupation
Business Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Whom may we thank for referring you?
May we contact them?
In case of emergency, who should be notified?*
First Last
Emergency Contact Phone*
Are you filling out this form for yourself?*
If you are a minor, select "No".
Name of person responsible for the account:*
First Middle Last
Relationship to client:*
Date of Birth*
MM slash DD slash YYYY
Will you be using insurance?*
Insurance Policy Holder's Name
First Last
Insurance Policy Holder Relationship to Client
Policy Holder's Date of Birth
MM slash DD slash YYYY
Insurance Policy Holder's Employer
Insurance Company
Policy Number
Group Number
Secondary Insurance Carrier
Insurance Acknowledgement*
I, the undersigned certify that I (or my dependent) has the above mentioned insurance coverage. I understand it is my responsibility to inform this office whenever any information on this form changes. I agree to present this office with a picture id card (driver’s license, miltary id, state id) and if applicable my insurance card. I understand that this office will make a copy of my id and insurance card to keep on file.
Name of Responsible Party*
First Last
Date*
MM slash DD slash YYYY
Signature of Responsible Party*
Relationship to Client
Signature of client if other than responsible party

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NOTICE OF PRIVACY PRACTICES
Acknowledgement of Privacy Practices*
THIS NOTICE IS EFFECTIVE 08/12/09

THIS NOTICE DESCRIBES HOW PERSONAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

PURPOSE OF THIS NOTICE

Our Office is required by law to maintain the privacy of certain confidential health care information, known as Protected Health Information (PHI), and to provide you with a notice of our legal duties and privacy practices with respect to your PHI. This Notice describes your legal rights, advises you of our privacy practices, and lets you know how our office is permitted to use and disclose PHI about you.

This Notice is covered under HIPAA (Health Insurance Portability & Accountability Act). Any state law that is more stringent than the HIPAA rules and regulations has priority.

We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, we will post a new Notice in our waiting area. You may request a copy of the new notice from our Privacy Officer, Damon Dye, by calling (813) 413-7575 or writing to the address provided below.

HOW WE MAY USE AND DISCLOSE YOUR PROTECTED MENTAL HEALTH INFORMATION

We use and disclose PHI for a variety of reasons. For most uses/disclosures, we must obtain your consent. However, the law provides that we are permitted to make some uses/disclosures without your consent. The following offers more description and examples of our potential uses/disclosure of your PHI.

Uses And Disclosures Requiring Your Consent:

• For treatment: We may disclose your PHI to other mental health care practitioners who are involved in providing your mental health care. For example, a referral to a mental health practitioner for assessment and/or long-term treatment would require a signed consent form from you for us to release and/or receive PHI about you to appropriately coordinate your care.

• For mental health care operations: We may use/disclose your PHI in the course of operating our Program. For example, we may use your PHI in evaluating the quality of services provided, creating reports that do not individually identify you, or disclose your PHI to our accountant or attorney for audit purposes.

• For Payment: We may use/disclose your PHI in the course of collecting outstanding payment from you. For example, If failure for paying on a bad check in a timely manner, we may employ the State Attorney’s office to collect on the outstanding debt. Or if failure to pay on your account in a timely manner, we may employ an attorney or collection agency to collect any outstanding debt.

Exceptions: Although your consent is usually required for the use/disclosure of your PHI for the activities described above, the law allows us to use/disclose your PHI without your consent in certain situations. For example, we may disclose your PHI if needed for emergency treatment if it is not reasonably possible to obtain your consent prior to the disclosure and we think that you would give consent if able. Also if we are required by law to provide your treatment, we may use/disclosure your PHI for treatment and operations without obtaining your prior consent.

Uses And Disclosures Requiring Authorization: For uses and disclosures beyond treatment and operations purposes we are required to have your written authorization (signed permission), unless the use or disclosure falls within one of the exceptions described below. Like consents, authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization.

Uses And Disclosures Requiring Authorization By A Minor: The law provides that we may not use/disclose a minor’s PHI to the parent/legal guardian without a consent or authorization in the following circumstances.

• When required by law: We may not disclose a minor’s PHI to the parent/legal guardian when a law requires that we keep confidentiality about:

• Substance Abuse/Chemical Dependency

• Pregnancy

• Abortion

Uses And Disclosures Not Requiring Consent Or Authorization: The law provides that we may use/disclose your PHI without consent or authorization in the following circumstances:

• When required by law: We may disclose PHI when a law requires that we report information about:

• Suspected abuse

• Neglect or domestic violence

• Suspected criminal activity

• In response to a court order

We must also disclose PHI to authorities who monitor compliance with these privacy requirements.

• For health oversight activities: We may disclose PHI for audits or government investigations, inspections, disciplinary proceedings, and other administrative or judicial actions undertaken by the government (or their contractors) to oversee the health care system.

• To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. For example, a plan to commit suicide or a homicidal act.

• For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.
Uses And Disclosures Requiring You To Have An Opportunity To Object: In the following situations, we may disclose your PHI if we inform you about the disclosure in advance and you do not object. However, if there is an emergency situation and you cannot be given your opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interest. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so.

• To family members, friends or others involved in your care: We may share with these people information directly related to their involvement in your care. We may also share PHI with these people to notify them about your location or general condition. For example, parents of a minor have certain rights to PHI. Also, we may have to locate family members to inform them of the location of a client who was hospitalized after being diagnosed as severely depressed.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION.

You have the following rights relating to your protected mental health information:

• To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law.

• To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so.

• To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information if you put your request in writing. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, but may be waived, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

• To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is (1) amended and complete; (2) not created by us and/or not part of our records; or (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will amend the PHI and so inform you, and tell others that need to know about the amendment in the PHI.

• To find out what disclosures have been made: You have the right to receive an accounting (which means a detailed listing) of disclosures that we have made. If you would like to receive an accounting, you may send us a letter requesting an accounting or contact our Privacy Officer. The accounting will not include several types of disclosures, including disclosures for treatment or disclosures for which you gave consent. It will also not include disclosures made prior to April 14, 2003. However, from that day forward, disclosures must be documented and retained for a period of 6 years. We will respond to your written request for such a list within 60 days of receiving it. There will be no charge for up to one such list each year/ (12) month period. There may be a charge for more frequent requests.

• To receive this notice: You have a right to receive a paper copy of this Notice and/or electronic copy by email upon request.

HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES

If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may file a complaint either with us or with the federal government. We will not take any action against you or change our treatment of you in any way if you file a complaint. You may file a written complaint with the Office for Civil Rights (OCR), U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth Street SW, Atlanta, GA 30303-8909.

CONTACT PERSON FOR INFORMATION OR TO SUBMIT A COMPLAINT AND QUESTIONS

If you have questions about this Notice or any complaints about our privacy practices, please contact:

Damon Dye, EdD, LMHC, BACC 6013 Brandon Circle, Riverview, FL 33578

I have received the Notice of Privacy Practices and I have been provided an opportunity to review and ask questions.
Today's Date*
MM slash DD slash YYYY
Client Name*
First Last
Client Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Client Signature*
Name of Parent/Guardian
First Last
Signature of Parent/Guardian

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Patient Record of Disclosures
Contact Method*
- Select All
- Home Phone
- Work Phone
- Cell Phone
- Written Communications to Email
- Written Communications to home address
Home Phone*
Select One*
Work Phone*
Select One*
Cell Phone*
Select One*
Email*
Client Name*
The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to use of disclosures otherwise permitted or required: (1) pursuant to an authorization requested by the individual, (2) for treatment, payment and healthcare operation purposes, (3) to individuals of PHI about them, (4) for the facility’s directory or to persons involved in the individual’s care or other notification purposes, (5) for national security or intelligence purposes, (6) to correctional institutions or law enforcement officials, (7) as part of a limited data set, (8) that occurred prior to the compliance date (April 14, 2003) for the covered entity, (9) or in an emergency. An accounting is provided once free of charge in any twelve (12) month period. If a second accounting is requested, there is a charge for the copy paper, copy machine, ink, time, etc.

In general, the HIPAA privacy rule gives individuals the rights to request a restriction on uses and disclosures of their Privacy Health Information (PHI). The individual is also provided the right to request confidential communications of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of home.
I WISH TO BE CONTACTED IN THE FOLLOWING MANNER
(SELECT ALL THAT APPLY) (APPOINTMENT REMINDERS INCLUDED)

Providing an o.k. to: Cell Phone/Email/Written Communication *(bold) ensures you the most effective office communication.
First Last
Date of Birth*
MM slash DD slash YYYY
Today's Date*
MM slash DD slash YYYY
Client Signature*
Name of Parent/Guardian
First Last
Signature of Parent/Guardian

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Client Treatment History
Please indicate if either of the following should be included when considering your treatment plan.
In order to provide the highest level of care, it is important that your therapist has as much information as possible regarding your well-being.
- Substance abuse (alcohol, drugs, controlled substances)
- Psychiatric history (past treatment, diagnoses, trauma, addictive behavior, medicines)
Burns Depression Checklist
Indicate how much each type of feeling has been bothering you in the past several days.
1. Sadness: Have you been feeling sad or down in the dumps?*
2. Discouragement: Does the future look bleak or hopeless?*
3. Low self esteem: Do you feel worthless or think of yourself as a loser?*
4. Inferiority: Do you feel inadequate or inferior to others?*
5. Guilt: Do you get self-critical and blame yourself?*
6. Indecisiveness: Is it hard to make decisions?*
7. Irritability and frustration: Have you been feeling angry or resentful?*
8. Loss of interest in life: Have you lost interest in your career, hobbies, family, or friends?*
9. Loss of motivation: Do you feel overwhelmed and have to push yourself to do things?*
10. Poor self image: Do you think you’re looking old or unattractive?*
11. Appetite changes: Have you lost your appetite? Or do you overeat compulsively?*
12. Sleep changes: Is it hard to get a good night’s sleep? Are you tired and sleeping too much?*
13. Loss of libido: Have you lost interest in sex?*
14. Hypochondrias: Do you worry a lot about your health?*
15. Suicidal Impulses: Do you think life is not worth living or think you’d be better off dead?*
Total Points
Burns Anxiety Inventory
Indicate how much each type of feeling has been bothering you in the past several days.
1. Anxiety, nervousness, worry, or fear*
2. Feeling things around you are strange or foggy*
3. Feeling detached from all of part of your body*
4. Sudden unexpected panic spells*
5. Apprehension or a sense of impending doom*
6. Feeling tense, stress, “uptight” or on edge*
7. Difficulty concentrating*
8. Racing thoughts*
9. Frightening fantasies or daydreams*
10. Feeling on the verge of losing control*
11. Fears of cracking up or going crazy*
12. Fears of fainting or passing out*
12. Fears of fainting or passing out*
13. Fears of illnesses, heart attacks or dying*
14. Fears of looking foolish in front of others*
15. Fears of being alone, isolated, or abandoned*
16. Fears of criticism or disapproval*
17. Fears that something terrible will happen*
18. Skipping, racing, or pounding of the heart*
19. Pain, pressure, or tightness in the chest*
20. Tingling or numbness in the toes or fingers*
21. Butterflies or discomfort in the stomach*
22. Constipation or diarrhea*
23. Restlessness or jumpiness*
24. Tight, tense muscles*
25. Sweating not brought on by heat*
26. A lump in the throat*
27. Trembling or shaking*
28. Rubbery or “jelly” legs*
29. Feeling dizzy, lightheaded or off balance*
30. Choking or smothering sensations*
31. Headaches or pains in the neck or back*
32. Hot flashes or cold chills*
32. Hot flashes or cold chills*
33. Feeling tired, weak, or easily distracted*
Total Points
Relationship Satisfaction Scale
1. Communication and openness*
2. Resolving conflicts and arguments*
3. Degree of affection and caring*
4. Intimacy and closeness*
5. Satisfaction with your role in the relationship*
6. Satisfaction with the other person’s role in the relationship*
7. Overall satisfaction with your relationship*
Total Points
Who did you have in mind when filling out this test:
Please indicate the type of relationship (spouse, colleague, friend, etc):

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Health Insurance Companies:

Triangle Resolutions accepts the following major insurance providers. As well as, Aetna EAP, Anthem EAP, Cigna EAP, Corporate Care Works EAP, & Humana EAP.
If your insurance is not listed, our office can also verify for any available out of network coverage with those non listed insurance carriers.