I. CLIENT INFORMATION
- Full Name:
ANSWER
Date of Birth:
DD/MMM/YYYY
Gender:
- [] Male
- [] Female
- [] Other: (state what here)
Marital Status:
ANSWER
Address:
ANSWER
Ethnicity:
ANSWER
Occupation:
ANSWER
Phone Number:
ANSWER
Email Address:
ANSWER (( Include your GTA World forum name & Discord username here. ))
II. EMERGENCY CONTACT INFORMATION
- Full Name:
ANSWER
Relationship to Client:
ANSWER
Phone Number:
ANSWER
Email Address:
ANSWER (( Include their GTA World forum name & Discord username here. ))
III. HISTORY AND BACKGROUND
- Relevant Medical History: (Include any relevant medical conditions, surgeries, or hospitalizations if applicable)
ANSWER
Substance Use History: (Include types of substances used, frequency, and duration of use, date of last use, previous attempts at recovery, and history of withdrawal symptoms if applicable)
ANSWER
Are there any mental health concerns or diagnoses you would like us to be aware of?
ANSWER
Is there any family history of substance abuse or mental health disorders that you believe is relevant to your situation?:
ANSWER
IV. APPOINTMENT DETAILS
- Preferred Appointment Date:
DD/MMM/YYYY
Preferred Appointment Time:
HH:MM
Types of Service Requested: (Mark multiple if applicable & click here to check out the types of services we provide in more detail)
- [] Initial Assessment & Evaluation
- [] Detoxification Services
- [] Outpatient Counseling Session
- [] Family/Couple Therapy
- [] Holistic Therapy
- [] Aftercare Planning
- [] Support Group Sessions
Is this appointment for:
- [] Self
- [] Spouse/Partner
- [] Child/Teen
- [] Other Family Member
- [] Friend/Relative
Brief Reason for Appointment Request: (Provide a brief overview of why you are seeking our services and any specific concerns or goals you have for the appointment)
ANSWER
V. LOGISTICS & PREFERENCES
- Do you have any specific accessibility needs or preferences we should be aware of?
ANSWER
Preferred Therapist or Provider: (Click here to find out more information about our team)
ANSWER
Do you have any language preferences for communication or therapy sessions? (By default, English is the main language for all appointments and sessions. Keep in mind that we don't promise to have a therapist or provider that meets your language needs)
ANSWER
VI. CONSENT
- I, [Your Full Name], understand and agree to the following terms regarding the collection, use, and disclosure of my personal information for appointment scheduling and treatment coordination purposes at Valentines Rehabilitation Center:
- I understand that the information provided in this form, along with any additional information collected during the appointment scheduling process and subsequent treatment, will be collected and stored securely by Valentines Rehabilitation Center.
- I consent to the use of my personal information for the purpose of scheduling appointments, coordinating treatment services, and maintaining accurate records related to my care at Valentines Rehabilitation Center.
- I understand that my personal information may be disclosed to healthcare professionals and staff directly involved in my care at Valentines Rehabilitation Center, including but not limited to therapists, physicians, nurses, and administrative staff. Additionally, I also acknowledge that my information may be shared with hospitals, medical facilities, and other healthcare providers as necessary for the transfer of care if required or coordination of services.
- I understand that my personal and health information will be kept confidential and will only be disclosed as necessary for the provision of treatment, as required by law, or with my explicit consent.
- I acknowledge that while Valentines Rehabilitation Center takes measures to safeguard the privacy and security of my information, no method of transmission over the internet or electronic storage is completely secure, and there may be risks associated with the transmission and storage of personal information.
- I understand that I have the right to access, review, and request corrections to my personal information held by Valentines Rehabilitation Center in accordance with applicable laws and regulations.
- I understand that my personal information will be retained by Valentines Rehabilitation Center for the duration necessary to fulfill the purposes outlined in this consent form and as required by law or professional standards.
- I understand that I have the right to revoke this consent at any time by providing written notice to Valentines Rehabilitation Center. However, I acknowledge that revoking consent may affect my ability to receive services or may result in the termination of treatment.
Signature:
ANSWER
Date:
DD/MMM/YYYY
