EmailMe Form - Client Intake Form

Client's Full Name *
First MI Last
If someone other than the client is completing this form, please indicate name and relationship to client here:
Client's Date of Birth *
MM / DD / YYYY
Client's Age *
Client's Gender
Client's Marital Status *
Single
Married
Divorced
Other
Client's Employment Status *
Employed Full Time
Employed Part Time
Full Time/Part Time Student
Unemployed
Retired
Other
Client's Occupation/Former Occupation
Phone Number *
### - ### - ####
Email Address *
May I leave a voice message *
Yes
No
Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
How did you hear about Jessica Wilkinson, LCSW? *
Emergency Contact Information
Emergency Contact's Name *
Emergency Contact's Relationship to Client *
Emergency Contact's Phone Number *
### - ### - ####
Health and Medical History
Primary Care Physician
Psychiatrist
Please list any current medical problems and major past medical problems.
If you are currently taking any medications for mental health treatment, please list those medications here.
Have you previously sought outpatient counseling? If yes, please provide the name of previous provider(s), length and frequency of treatment.
Have you ever been hospitalized for mental health treatment? If yes, please provide the name of hospital and dates of treatment.
What areas are you struggling with that brought you to counseling? *
Policies
Please initial each policy to acknowledge that you have read and agree.
If for any reason you need to cancel and/or reschedule an appointment, please notify the office immediately. For all cancellation or reschedule notices received with less than a 24 business hour notice, there will be a $50 fee assessed to the card on file. If for any reason you do not attend your session, you will be charged the full session fee of $100. If you arrive 15 minutes or more late to your appointment, your appointment will be considered missed and your card on file will be charged the full session fee of $100. *
Cancellation/No Show/Late Arrival Policy
The card you provide on file will be assessed any applicable fees and will be processed in less than 24 hours of all scheduled appointments. A receipt for the paid session/fee will be provided upon request. Methods of acceptable payment include credit cards, debit cards, and personal check. *
Payment Policy
This office does not provide assistance to patients wishing to obtain paperwork for any type of disability and/or time off of work. This office does not make any diagnoses judgements for disability in conjunction with such diagnoses.

For any and all legal matters (subpoenas, court appearances, depositions, any and all written and/or typed materials requested or any other such legal matter), please contact the office directly. Please provide at least a one month notice for any such request. Rates for any such legal matters are $300 per hour and if travel is mandatory, all travel expenses are to be paid in full. For any court appearance or deposition, a $1500 retainer must be paid in full at least 2 weeks prior to the scheduled date. If the fees for the service total less than the $1500 retainer, such monies will be reimbursed within one month. If the fees for the service total more than the $1500 retainer, payment will be expected in full at the time such services are rendered. If a deposition and/or court appearance is scheduled, but for any reason was cancelled and/or such services are no longer requested, the $1500 retainer will be reimbursed in full as long as an appropriate two week notice (10 regular business days) is given. If such a notice is given in less than two weeks, but at least one week (5 business days), then $1000 will be reimbursed. Any notice given under 48 hours will be assessed the full $1500 in which the $1500 retainer fee will not be reimbursed. If the above information is not addressed accordingly, such legal matters will be sent directly to Southern Senior Care Consulting LLC's attorney.

Requests for documentation of counseling services will simply be a brief summary in which the dates of services and a very brief, maybe one sentence general statement regarding the reasons for attending counseling will be provided. Only the adult patient themselves or the legal guardian who has permission for such information may be provided with this summary.

If you are requesting documentation of services for legal purposes, only the same summary above will be provided and only provided to the same parties as detailed above. A $25 fee will be assessed to the card on file for such a summary. A notice of at least 5 business days must be provided for such a summary.

To be processed with the card on file, there shall be a fee of $25.00 assessed for all phone conferences and other communications initiated by the patient and/or guardian with the counselor outside the office setting. You are highly encouraged to make an appointment if you need to speak with the counselor.

To be processed with the card on file, all detailed reports and correspondence will be assessed a rate of $150/hour. Detailed reports require a 30 day notice and payment in full before documents will be sent.

Our office is HIPPA compliant in regards to policies and procedures. While remaining HIPPA compliant, our office operates electronically in regards to patient information such as billing and charting sessions. Session notes are filed and stored with a fully encrypted data center. *
Disability/Legal Matters
My (digital) signature below signifies that I have read and agree to the policies listed above.

Your Signature *
By entering your name here, you are digitally signing this online form
I understand that I am financially responsible for all charges and Jessica Wilkinson, LCSW is not accepting health insurance at this time.

Your Signature *
By entering your name here, you are digitally signing this online form
A credit/debit card on file is required for all new clients and existing clients. Please note that it will be required at the time of your initial session.

Your Signature *
By signing this form, you agree to the financial responsibilities stated above and authorize Southern Senior Care Consulting LLC to charge the credit card or debit card on file for: 1) All appointments scheduled, to be processed within 24 hours or less of scheduled appointments; 2) Missed appointments; 3) Appointments that are cancelled with less than a 24-hour notice; 4) Non-payment of any outstanding claims of 30-days or greater; 5) A returned check by your bank. Credit card will be charged for cost of service as well as any applicable bank fees. There is a minimum $30 NSF per returned check.
Declarations of Practices and Procedures for Jessica Wilkinson, LCSW
Qualifications. I earned a Master of Social Work Degree from University of Arkansas at Little Rock in 2015. I am a Licensed Clinical Social Worker (#15878) with the Louisiana State Board of Social Work Examiners, which is located at 18550 Highland Road, Suite B, Baton Rouge, LA, 70809 (phone 225-756-3470). I earned a Certificate of Gerontology from University of Arkansas at Little Rock in 2015. Counseling Relationship. I see the counseling relationship as one that must be based on mutual trust, respect, and honesty. I use a variety of theoretical approaches in attempt to match client’s needs. I primarily use techniques based in Cognitive-Behavioral Theory in which strategies are used to help modify patterns of thought and actions to promote mental health, wellness, and personal growth. Our first one to three sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Areas of Expertise. My focus includes working with older adults and their caregivers to address issues related to dementia, health and safety concerns, loss/grief, end-of-life, and Advance Directives. In addition to providing resources for families to assist with these challenges, I work with caregivers to treat anxiety or depression and with older adults to treat anxiety, depression, or acute stress disorder. Fee Scales. All therapy sessions are $100 for a one-hour session. After the initial session, clients can request care management services outside of sessions for a fee of $60 per hour billed in 30 minute increments. I also offer a limited number of reduced rate fee slots for clients in need of reduced rates. Reduced rate therapy fees are $50-$75 per one-hour session, and reduced rate care management fees are $30-$45 per hour billed in 30 minute increments. Services Offered and Clients Served. I work with clients in a variety of formats, including individual, group and family therapy. I see clients of all backgrounds with ages ranging from eighteen to one hundred and five years. Younger clients should be caring for an older adult to be within my scope of practice. Code of Conduct. As a Licensed Clinical Social Worker, I adhere to the Louisiana State Standards of Practice for Credentialed Social Workers. A copy of these standards is available upon request.
Confidentiality
In general, the privacy of all communications between a client and a therapist is protected by law, and I can only release information about our work to others with your written permission. There are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency or contact law enforcement. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I do not reveal identifying information about my client. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Emergency Situations
Emergency services are not provided. Clients may send messages via email and I will respond via phone or email as soon as possible. If an emergency situation should arise, you may seek help at the nearest emergency room. Otherwise call 911; the COPE Team at Our Lady of the Lake Hospital (225)765-8900 or (800)864-9003; or the Baton Rouge Crisis Intervention Center at (225)924-3900 or (800)437-0303.
Client Responsibilities
I see counseling as a collaborative process, meaning you are a full partner in counseling. Your honesty and effort are essential to success. If, as we work together, you have suggestions or concerns about your counseling, I expect you to share those with me so we can make the necessary adjustments. If it becomes apparent that you would be better served by another mental health provider, I will help you with the referral process. If you are seeing another mental health professional, please inform me. With your permission, I will contact that professional and develop a collaborative relationship.
Physical Health
Physical health can be an important factor in the emotional well-being of an individual. If you have not had a physical examination in the last year, it is recommended that you do so. Additionally, medications, both prescription and non-prescription, may have significant side effects that may impact the counseling relationship. I expect full disclosure from you regarding any and all medications that you are currently taking and may ask permission to discuss them with your physician/medical doctor.
Potential Counseling Risk
You should be aware that counseling poses potential risks. In the course of working together additional problems may surface of which you were not initially aware. If this occurs, you should feel free to share these new concerns with me. Since counseling often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
Contacting Me
I am often not immediately available by email or telephone. I will not answer messages when I am with a client. I monitor my emails frequently. I will make every effort to return your message on the same day you send it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
Professional Records
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents.
Email and Online Therapy
I do not provide therapy via text, email, Skype, or telephone. Phone calls are not a substitute for in-person therapy, and I will not discuss therapeutic issues via email or text. With the exception of calling to notify me of an emergency and the need to meet in person, you acknowledge that phone calls/emails are not to be used for suicidal thoughts, thoughts of harming others, or other life-threatening emergencies, hallucinations/dissociative disorders, intimate partner violence, or elder abuse issues. You agree to take responsibility for maintaining the confidentiality of any emails you send/keep on your computer and any phone conversations.
Consent to Treatment
I have read and understand the above information and give permission for Jessica Wilkinson, LCSW to conduct counseling with me (as the client and/or the power of attorney/legal guardian of the client). I understand that I may stop such treatment or services at any time.
Acknowledgement of Receipt of Privacy Notice and Release of Information
I have been presented with a copy of Jessica Wilkinson, LCSW’s Notice of Privacy Policies detailing how my information may be used and disclosed as permitted under federal and state law. I also have the opportunity to take home a copy of the policy. I understand that no one, including family members, will be allowed access to any information regarding my treatment or billing information, to include but not limited to, my diagnosis, prognosis, attendance, any and all progress/treatment notes, information regarding compliance with counseling, recommendations for future counseling services and any other information necessary for such coordination of care and any other information requested from person/agency/other to whom information is to be released, unless I include them on a list provided to Jessica Wilkinson, LCSW. I understand that this office cannot accept my verbal permission to release my information. I also understand that I can change this list at any time.
Client Signature *
Date Time
MM / DD / YYYY

Emergency Contact Information

Health and Medical History

Policies