The Anxiety & OCD Therapy Practice

New Patient Intake

Welcome. Please complete this form before your first appointment. All information is confidential and HIPAA-compliant.

Confidential · HIPAA Compliant · Secure

~5 Minutes

100% Secure

Please note: This form must be completed in full before your first session can be confirmed. If you have any questions, please call or text us at (845) 288-3139 or email us at info@anxiety-ocdtherapy.com.

Let's get started

Full Name *

Email Address *

Section 1 of 7

Contact Information

Please provide your basic contact details.

Phone Number *

Street Address *

City / State *

Zip Code *

Date of Birth *

Referral Source *

Section 2 of 7

Policy & Payment

Please read the policy statement carefully and provide payment information.

Policy Statement

Confidentiality

Information disclosed to a mental health provider is typically confidential and may be protected under legal privilege. This confidentiality extends to all information, except that which could jeopardize the safety of the patient or others. As mandated reporters, your provider is required to report any suspicions of child or elder abuse. Should the need arise to share your information with external parties, your provider will discuss this with you. We utilize HIPAA-compliant electronic communication methods. Our videoconferencing platform (Zoom) complies with HIPAA standards.

Fees & Payment

Standard sessions last approximately 45 minutes and are billed accordingly. Our fee is $250 per session with payment due at the beginning of each session. If there is an outstanding balance at the start of a session, you will be required to reschedule. Accepted payment methods include checks payable to The Anxiety & OCD Therapy Practice, cash, or credit card. All clients must maintain a credit card on file.

Insurance

The Anxiety & OCD Therapy Practice operates on an out-of-network basis and does not accept insurance plans. It is the patient's responsibility to verify any out-of-network benefits with their insurance provider. Superbills will be provided on a weekly or monthly basis for sessions paid in full.

Cancellation & No Show Fee Policy

The Anxiety & OCD Therapy Practice reserves the right to impose fees for missed appointments or cancellations made with less than 48 business hours' notice. These fees will be automatically charged to your credit card on file. Cancellations made within 48 hours or no-shows will incur a charge of the full session fee.

Therapist Availability

Our voicemail system is operational 24 hours a day, seven days a week. Calls related to appointment scheduling or non-clinical advice will be returned during regular office hours: Monday through Thursday, 9:00 a.m. to 5:00 p.m. Please allow up to 24 hours for a return call.

Process and Outcomes of Therapy

Achieving successful therapeutic outcomes involves various factors, many of which are outside the therapist's control (e.g., the client's commitment to applying therapy skills). Therefore, The Anxiety & OCD Therapy Practice does not guarantee specific results.

In Case of Emergency

In the event of an emergency where you need immediate assistance, please go to the nearest hospital emergency room or call 911.

I have read and agree to the above policy, including the 48-hour cancellation fee *

Date *

Credit Card Information

Optional — may provide by phone

This form is secure. If you prefer, you may call (845) 288-3139 to provide this information. Sessions cannot be confirmed until payment information is on file.

Name on Card

Credit Card Number

Expiration Date

Security Code

Billing Zip

Signature Authorizing Card Usage

Section 3 of 7

Main Concern

Help us understand what's bringing you to therapy.

Briefly describe what is bringing you to therapy *

How intense is your emotional distress? *

1 = Low · 10 = High

Low High

— tap to answer —

How much do these problems affect your ability to function? *

1 = Mildly disruptive · 10 = Incapacitating

Mildly disruptive Incapacitating

— tap to answer —

Please describe how it affects you

Section 4 of 7

Relationships & Family

Tell us about your current relationships and family situation.

Are you currently in a relationship?

Yes No Other

Do you have any children?

Yes No

Section 5 of 7

Mental Health History

This helps us understand your background and provide the best care.

Have you ever been on psychiatric medication?

Yes No

Are you currently taking any psychiatric medication?

Yes No

Have you ever been to therapy?

Yes No

Over the past 30 days, how would you describe your mood?

Sadness

I am sad once in a while I am sad much of the time I am sad all the time

Future Outlook

I feel pretty good about my future I feel more discouraged than I used to I feel like my future is hopeless

Pleasure

I get as much pleasure as I ever did I don't enjoy things as much as I used to I get very little pleasure from things I used to enjoy

Do you have any history of suicidal ideation or self-injurious behavior? *

Yes No

Please provide information about any current or past mental health history within your family

Section 6 of 7

Physical Health & Lifestyle

Your physical health and habits help us understand the full picture.

How would you rate your physical health? (1–10)

Poor Great

— tap to answer —

Any specific health problems you are currently experiencing?

Have you experienced recent weight gain or loss?

Yes No

Have there been recent changes to your sleep or eating habits?

Yes No

How much sleep do you get on average?

Do you get restful sleep?

Yes No

Do you currently consume alcohol?

Yes No

Describe your caffeine use

Do you smoke or use any tobacco products?

Yes No

Section 7 of 7

Additional Information & Goals

Just a few more questions to complete your intake.

Do you have any spiritual or religious beliefs?

Yes No

Have you ever experienced or been exposed to any form of trauma?

Yes No Prefer not to answer

Are you currently employed or in school?

Yes No

What would you like to accomplish in therapy? *

Is there anything else you would like to mention?

✓

Thank You

Your intake form has been submitted successfully. We will be in touch shortly to confirm your appointment.

Questions? Call or text us at (845) 288-3139

Or email info@anxiety-ocdtherapy.com

Return to Website

Call Us +1-555-555-555

New Patient Intake

Let's get started

Contact Information

Policy & Payment

Policy Statement

Confidentiality

Fees & Payment

Insurance

Cancellation & No Show Fee Policy

Therapist Availability

Process and Outcomes of Therapy

In Case of Emergency

Credit Card Information

Main Concern

How intense is your emotional distress? *

How much do these problems affect your ability to function? *

Relationships & Family

Are you currently in a relationship?

Do you have any children?

Mental Health History

Have you ever been on psychiatric medication?

Are you currently taking any psychiatric medication?

Have you ever been to therapy?

Over the past 30 days, how would you describe your mood?

Do you have any history of suicidal ideation or self-injurious behavior? *

Physical Health & Lifestyle

How would you rate your physical health? (1–10)

Do you exercise?

Have you experienced recent weight gain or loss?

Have there been recent changes to your sleep or eating habits?

Do you get restful sleep?

Do you currently consume alcohol?

Do you use any recreational drugs?

Additional Information & Goals

Do you have any spiritual or religious beliefs?

Have you ever experienced or been exposed to any form of trauma?

Are you currently employed or in school?

Thank You

Interested to learn more? We’re here to help!

The Anxiety & OCD

Therapy Practice

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