Common use of Primary Language Clause in Contracts

Primary Language. Was the client adopted? Yes No Is the client a student? Yes No Part-Time Student Full-Time Student Highest grade/education/degree completed Separated Divorced Engaged Partners Spouse/Partner’s Name: Soc. Sec. #: (Last) (First) (Middle Initial) Gender: M F Age: Birth date: Length of Relationship: Work # Home # Cell # If separated: Address, City, State & Zip Occupation of Spouse Employer: Employer Phone # ( ) Check One: Employed Full-Time Employed Part-Time Unemployed Employer Address _ City, State, Zip: How long working for the current employer? What is their gross income? (We may need this income to set your fee) Brochure/Flyers Internet Yellow Pages Another Therapist Minister/Priest/Rabbi Word of mouth Other Signature of Client Date Signature of Parent/Legal Guardian/▇▇▇▇▇▇ Parent/Conservator/Other Date (Required if participant is a minor, under age 18) Spouse/Partner Child Other What is the insurance company name? Billing Address Phone Number ( ) Is it a PPO? [ ] or HMO? [ ] Membership/Benefit Policy Number Group # Plan # Effective Date: / / How much coverage do you have in a year? Have you met your deductible? Yes No What are your insurance company’s credential requirements for pursuing counseling? (e.g. licensed MFT, registered social worker, etc.) Secondary Insurance: Insured is: Self Spouse/Partner Child Other What is the insurance company name? Billing Address Phone Number ( ) Is it a PPO? [ ] or HMO? [ ] Membership/Benefit Policy Number Group # Plan # Effective Date: / / How much coverage do you have in a year? Have you met your deductible? Yes No Whatareyourinsurancecompany’scredentialrequirementsforpursuingcounseling?(e.g.licensedMFT Social worker.)

Primary Language. Was the client adopted? Yes No Is the client a student? Yes No Part-Time Student Full-Time Student Highest grade/education/degree completed Separated Divorced Engaged Partners Spouse/Partner’s Name: Soc. Sec. #: (Last) (First) (Middle Initial) Gender: M F Age: Birth date: Length of Relationship: Work # Home # Cell # If separated: Address, City, State & Zip Occupation of Spouse Employer: Employer Phone # ( ) Check One: Employed Full-Time Employed Part-Time Unemployed Employer Address _ City, State, Zip: How long working for the current employer? What is their gross income? (We I may need this income to set your fee) BrochureWhy are you seeking help now? What would you like to see happen as a result of counseling or psychotherapy? Psychiatrist’s Name: Psychiatrist’s Phone: Have you ever had counseling or psychotherapy in the past? Yes No If yes, when? With whom? Current Medication Dosage Frequency Prescribing MD Have you or any other family member received help for drug or alcohol dependency? Yes No If yes, when? Where? Caffeine: Tobacco: Coffee Sodas Other drinks Pills Alcohol: Marijuana: Cocaine, Crack: LSD: Inhalants: Other: Have you been concerned or ever felt guilty about your use of drugs/Flyers Internet Yellow Pages alcohol? Yes No Has anyone ever expressed concern about your use of drugs/alcohol? Yes No If yes, who? Have you ever had a DUI? Yes No If yes, how many? When? Have you ever felt the need to cut down on your use of drugs/alcohol? Yes No Have you or others ever felt annoyed by criticism of your use of drugs/alcohol? Yes No Have you ever needed drugs/alcohol to get going in the morning, to function at work or social events, or to cope with withdrawal symptoms? Yes No Anger/frustration/hostility Anxiety, nervousness Attention, concentration, distractibility Confusion Depression Disliking others Emptiness Euphoria Excessive worry Failure Fatigue Fear Grieving (death, loss, divorce, etc) Guilt Hearing things other people don’t Homicidal thoughts Intrusive thoughts Judgment problems Memory difficulties Negative thoughts Obsessive thoughts Oversensitivity to criticism Oversensitivity to rejection Panic attacks Perfectionism Sadness Seeing things other people don’t Self-centeredness Self-esteem Shyness Spiritual, religious, or moral issues Stress Sudden mood changes Suicidal thoughts Suspiciousness Temper problems Thoughts of hurting self or others Aggression, violence Alcohol use Argumentative Avoidant Compulsive behavior/rituals Controlling  Decreased/lack of sexual interest Dependency Destruction of property Drug use – prescription, over-the-counter, street Eating problems Financial problems, debt Gambling Hyperactivity Internet problems Irresponsibility Isolation Legal problems Letting others take advantage of you Lying Not able to relax Loss of interest on what I used to like Loss of appetite Overeating Pornography Preoccupation with sex Procrastination Purging Self destruction/sabotaging Self-neglect Sexual dysfunction Smoking Stealing Sleep difficulty Threats Weight gain or loss Withdrawal from others  Self-injurious behavior Sexual promiscuity Infidelity Childhood issues (your childhood) Divorce Friendships Housework/chores Interpersonal conflicts Parenting Problems with child(▇▇▇) Problems with parents Problems with spouse/partner Separation Abuse of alcohol Abuse of drugs Emotional abuse by another Emotional abuse of another Financial abuse Neglect Physical abuse by another Physical abuse of another Sexual abuse by another Sexual abuse of another Verbal abuse Absenteeism Career concerns, goals, choices Difficulty with coworkers Difficulty with supervisor Performance Tardiness Procrastination School problems  I have no problems or concerns bringing me here at this time. Another Therapist Minister/Priest/Rabbi Word of mouth Other Signature of Client Date Signature of Parent/Legal Guardian/▇▇▇▇▇▇ Parent/Conservator/Other Date (Required if participant is a minor, under age 18) Spouse/Partner Child Other What is the insurance company name? Billing Address Phone Number ( ) Is it a PPO? [ ] or HMO? [ ] Membership/Benefit Policy Number Group # Plan # Effective Date: / / How much coverage do you have in a year? Have you met your deductible? Yes No What are your insurance company’s credential requirements for pursuing counseling? (e.g. licensed MFT, registered social worker, etc.) Secondary Insurance: Insured is: Self Spouse/Partner Child Other What is the insurance company name? Billing Address Phone Number ( ) Is it a PPO? [ ] or HMO? [ ] Membership/Benefit Policy Number Group # Plan # Effective Date: / / How much coverage do you have in a year? Have you met your deductible? Yes No Whatareyourinsurancecompany’scredentialrequirementsforpursuingcounseling?(e.g.licensedMFT Social What are your insurance company’s credential requirements for pursuing counseling? (e.g. licensed MFT, registered social worker.)