Journey Ahead Resources - Client Intake Packet

Journey Ahead Resources

Janet Mitchell, LCSW

609 Airport North Office Park
Fort Wayne, IN 46825
(260) 255-5085
New Client Intake Form
Client Information
Last Name
First Name
Date of Birth
Street Address
City
State
ZIP Code
Phone Number
Email Address
Pronouns
Emergency Contact
Name
Relationship
Phone Number
Reason for Seeking Services
Please describe what brings you to therapy:
Current Concerns
Check all that apply:
Anxiety
Depression
Trauma / PTSD
Grief / Loss
Relationship Issues
Stress Management
Self-Esteem
Life Transitions
Other: _______________
Treatment History
Have you previously been in therapy?
Yes
No
If yes, please describe (when, where, for what concerns):
Current medications (include name and dosage):
Goals for Therapy
What do you hope to achieve through therapy?

Journey Ahead Resources

Janet Mitchell, LCSW

609 Airport North Office Park
Fort Wayne, IN 46825
(260) 255-5085
Informed Consent for Treatment
Psychotherapy Services

Psychotherapy is a collaborative process between therapist and client. It varies depending on the individuals involved and the particular concerns being addressed. Therapy requires your active participation, including working on topics discussed during sessions and between appointments.

Psychotherapy has both benefits and risks. You may experience uncomfortable feelings such as sadness, guilt, anger, frustration, or helplessness when discussing difficult aspects of your life. However, psychotherapy has been shown to provide significant benefits including improved relationships, solutions to specific problems, and reductions in feelings of distress.

EMDR Therapy

Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based therapy approach that helps process traumatic memories and reduce their emotional intensity. EMDR may cause temporary disturbances including heightened emotions, physical sensations, or vivid dreams between sessions. These effects typically diminish as treatment progresses.

Confidentiality

Communications between client and therapist are generally protected by law and cannot be disclosed without your written consent. However, there are legal exceptions requiring disclosure:

1. Suspected child abuse or neglect, or abuse/neglect of elderly or dependent adults
2. If you present a serious danger to yourself or others
3. Court order requiring disclosure of treatment information

Appointments & Cancellation Policy

24-Hour Notice Required: If you need to cancel or reschedule an appointment, please provide at least 24 hours notice. Late cancellations (less than 24 hours) or missed appointments will be charged a fee of $50. This fee cannot be billed to insurance and is the client's responsibility.

Acknowledgment & Consent

Please read each statement and initial to indicate your understanding:

I have read and understand the information about psychotherapy services.
I understand that confidentiality has legal limits as described above.
I understand the 24-hour cancellation policy and agree to pay the $50 fee for late cancellations.
I understand I have the right to ask questions and to terminate therapy at any time.
I consent to receive psychotherapy services from Janet Mitchell, LCSW.
Client Signature
Printed Name
Date

Journey Ahead Resources

Janet Mitchell, LCSW

609 Airport North Office Park
Fort Wayne, IN 46825
(260) 255-5085
Notice of Privacy Practices (HIPAA)
Your Health Information

This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

Each time you visit Journey Ahead Resources, LLC, a record of your visit is made. This information serves as: a basis for planning your care and treatment; a means of communication among health professionals; a legal document describing the care you received; and documentation for billing purposes.

Uses and Disclosures of Health Information

Treatment: We may use your health information to provide, coordinate, or manage your treatment and related services with other health care providers.

Payment: We may use and disclose your health information to bill and collect payment for services. This may include contacting your insurance company to verify coverage or obtain prior authorization.

Health Care Operations: We may use your health information to support business activities including quality assessment, staff training, licensing, and accreditation.

Your Rights

You have the right to:

• Inspect and obtain a copy of your health record
• Request amendment of your health information
• Request an accounting of disclosures
• Request restrictions on certain uses and disclosures
• Request confidential communications
• Obtain a paper copy of this notice upon request

Questions and Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

Acknowledgment of Receipt
I acknowledge that I have received a copy of the Notice of Privacy Practices for Journey Ahead Resources, LLC. I understand how my health information may be used and disclosed as described in this notice.
Client Signature
Printed Name
Date
For Office Use Only
Client refused to sign
Staff Initials
Date

Journey Ahead Resources

Janet Mitchell, LCSW

609 Airport North Office Park
Fort Wayne, IN 46825
(260) 255-5085
Insurance & Payment Information
Payment Method
Insurance
Self-Pay ($125 per session)
Insurance Information
Insurance Company
Phone Number
Member ID
Group Number
Policyholder Information (if different from client)
Policyholder Name
Date of Birth
Relationship to Client
Fee Schedule
Initial Assessment (60 minutes) $150.00
Individual Therapy Session (45-50 minutes) $125.00
Late Cancellation / No-Show Fee $50.00
Authorization & Financial Responsibility
I authorize Journey Ahead Resources, LLC to release any information necessary to process insurance claims on my behalf.
I authorize payment of medical benefits directly to Journey Ahead Resources, LLC for services rendered.
I understand that I am financially responsible for all charges, including copays, coinsurance, deductibles, and any services not covered by insurance.
I understand that if my insurance denies a claim or I do not have coverage, I am responsible for the full fee.
Client / Responsible Party Signature
Printed Name
Date