New Client Confidential Initial Session Form

Each person participating in therapy with Dr. Fuller will need to complete this initial session form prior to the first session. If you are coming with children or adolescents please complete one form for each person. If you are coming with a spouse please ensure they complete the form prior to the session. After you have entered the information click submit. You will also need to sign a consent to treatment and financial agreement prior to the first session. If you have any difficulty with the form please contact our office for a paper copy. (832) 848-0870 OR Margaritat@fullerlifefamilytherapy.org.

AMF Initial Session Form

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Salutation

Mr.

Mrs.

Ms.

Dr.

Today's Date: *

First Name *

Last Name *

Nickname

Please list of names of persons attending therapy with you

Street address *

City *

State *

Zip Code *

Main Phone (10 digits) *

Type of phone

Mobile

Work

Home

Other

Is it OK to leave a message at this number? *

Yes

Please indicate if text Messages, related only to scheduling, may be sent to this number.

Yes

Other Phone

Type of phone?

Work

Home

Mobile

Other

Is it ok to leave a message at this number?

Yes

Please indicate if text Messages, related only to scheduling, may be sent to this number.

Yes

Email *

Email is not always a secure way to communicate. Please indicate if you would like email encrypted. *

No, Normal Email

Yes, Encrypted email

No email please

Would you like to receive resources from Fuller Life about relational, mental and emotional health? *

Yes, I do want resources from Fuller Life

No, I do not want to receive resources from Fuller Life

Would you like an email appointment reminders? (Only 1 email per family. Emails are not encrypted)

Yes

Type of therapy *

Names and Ages of all who live in the home:

Date of birth * Please type if calendar feature does not work. (Format: xx/xx/19xx)

Sexual Orientation

Gender *

Male

Female

Transgender

Marital Status *

If married or cohabitating, name of partner/spouse:

If Married, Date of Anniversary Please type in date (XX/XX/XXXX) if calendar does not work

Ethnicity

Religion

Would you like spirituality to be part of therapy?

Yes

Unsure

Please describe your level of activity with the above religious/spiritual practice.

Active

Somewhat Active

Inactive

N/A

Highest level of education

Employer

Occupation or Job Title

How did you hear about Fuller LIfe?

What are your reasons for seeking therapy? *

Please describe any previous counseling (Type of treatment, length,name of professional and outcome)

Please check one primary concern or symptom below: *

Please select any symtoms you have experienced in the last 2 weeks:

Pleas comment on above concerns or symptoms

Please check any that are a part of your history.

Please share relevant information about your medical, familial, mental, or employment history.

Name of primary physician

Primary Physician Phone

Please list all current medications, dosage, reason for medication and prescribing physician

Please provide a contact in the case of emergency *

Please provide a phone number for the emergency contact

Please describe your relationship with the emergency contact

Please provide the name of the party responsible for payment for therapy services *

Please provide a phone contact for the party responsible for payment of therapy services *

Please describe your relationship to the responsible party *

Self

Parent

Spouse

friend

Other

If you would like to use your insurance or find out what your benefits, list insurance name:

Insurance ID number

Insurance company phone number for behavioral health or customer service

List the zip code for the insurance claim address

Please provide any additional comments

Please select the name of your therapist:

Amy Fuller PhD, LMFT-S, LPC-S

Please type your name as an electronic signature. Additional Signatures will be required in person.