Today’s Date *
Name *
Date of Birth *
Age *
Address *
City *
Zip *
Home Phone *
Work Phone
Cell Phone
Do I have your permission to leave a voice mail message at these numbers? * YesNo
What is the best number to reach you at? *
Occupation *
Employer *
Highest Grade Level *
Height
Weight
Marital Status SingleMarriedDivorcedSeparatedOther
Spouse’s Name
Spouse’s Age
Children’s Names and Ages
Who may I thank for referring you?
Depressed mood
Overeating / under eating
Feeling keyed up / on edge
Difficulty concentrating
Sleep problems
Low energy
Low self esteem
Difficulty making decisions
Feeling hopeless
Anxiety
Difficulty sleeping
Poor appetite
Feeling shaky
Sexual issues
Restlessness
Difficulty in school or work
Interpersonal / social problems
Family issues
Childhood issues
Substance abuse / addiction issues
Trauma
TBI / Concussion
Internet / Video Game Issues
Please answer honestly. All answers are strictly confidential
Current medications and purpose: *
Substances used past 30 days: *
Prior substances used (alcohol or drugs): *
Age of first sexual experience / contact: * 0-45-1010-1212-1616-1818-2121+None
Have you ever been sexually abused? * YesNo
Have you ever been physically abused? * YesNo
Previous Therapy, Counseling or Coaching (place/length): *
Have you ever attempted suicide? *
Have you had suicidal ideas/thoughts? *
Feelings towards mother: *
Feelings towards father: *
Siblings: *
Other significant relationships: *
Religious / spiritual affiliation: *
Current occupation / grade level: *
Describe your reasons for coming to counseling or coaching: *
State your goals for counseling or coaching: *
I Agree to the Fee Agreement *
Cancellation must be made 24 hours in advance. I understand that if cancellation is made less than 24 hours in advance for any reason I will be charged the regular session rate.
I agree to the Cancellation Fee *
I, ______________________________ am willingly and voluntarily entering into counseling and/or professional coaching, and/or intervention services with Randy Moraitis, PhD, CIP, BCPC, CADC II, ICADC. I hereby voluntarily assume any and all risk of injury, mental, spiritual, emotional, physiological and/or physical harm, any personal loss and/or damage resulting from my personal counseling with Randy Moraitis, PhD, CIP, BCPC, CADC II, ICADC. Randy is a Board-Certified Diplomate of Positive Neuropsychology, Board-Certified Licensed Pastoral Counselor, Certified Drug and Alcohol Counselor, Certified Life Coach, Certified Recovery Coach, and Board-Certified Intervention Professional.
I Agree to the Consent / Release of Liability (Type Name) *
Confidentiality means that whatever is shared between client and counselor remains between client and counselor. Additionally, it is the client’s choice to share with other’s that they are seeing a counselor.
The only times that this confidence can be broken is in the event that the client reveals to the counselor that they want to hurt themselves or another, or have been involved in the abuse of a minor or elder.
Limits of Communication outside session Voicemail, email, and texting: are a means to communicate specific details such as scheduling or canceling an appointment. They are limited interactions and not a form of counseling.
Phone calls: any phone call exceeding 10 minutes is subject to prorated hourly billing. In some cases, “Phone Sessions” or “Facetime” may be prearranged.
Any type of social media interaction is not a form of counseling and is not a confidential setting.
I understand confidentiality and the limits of communication outside of counseling sessions.
I Agree to the Confidentiality Agreement *
Coaching packages are intended to gain a full commitment from the client and are therefore not refundable. If the client is unable to complete the sessions in the package, they are transferrable within the client’s family.
Using your credit or debit card is one option for paying the counseling session fees. Filling out this form gives Randy Moraitis permission to run your card. Your card will never be charged without your permission or knowledge, and this information will always remain secured in your file.
Credit card number:
Expiration date:
CCV code: (3 or 4 digit code on the back of your card)
Zip code of billing address:
Randy Moraitis has my permission to run my credit/debit card:
Signature
Date
