Kelli Underwood
Page 1
Adult Intake Form
Name of Client:
Mailing Address:
Physical Address (if different):
May I send mail to the above address? Y / N
Telephone #:_
Telephone Numbers (Please provide only confidential numbers that you give me permission to call and
leave detailed messages).
#:
Home Work Cell
#:
Home Work Cell
Any other numbers you would like for me to have?
How would you like to communicate about appointments (making, changing or cancelling)? Check
all that are acceptable.
Text
Email
Phone
Are emailed invoices acceptable to you?
Yes / No
If yes, what email address?
Primary Care Physician:_ _____________________________Telephone#:
Date of Birth/Age:_____________________
Relationship Status: _
Contact Person in case of emergency:
Student status/Occupation:
Have you ever engaged in therapy before? Y / N
Describe the reasons you are seeking therapy.
What are your goals for treatment?
(use the back of this page, if needed).
Worked with a psychiatrist? Y / N
Child and Adolescent Intake Form
To be filled out by parent or guardian requesting services for a minor child. This information will be
kept confidential.
Today’s Date:
Child’s Name
Date of birth:
Child lives with
Address of child’s primary residence
If parents/ guardians are divorced, describe custody agreement:
Contact information:
Name of family member
Relationship
Phone 1
Phone 2
Please indicate with an asterisk (*) which numbers are permissible for leaving detailed messages.
Who does the child live with?
Name
Relationship
Occupation
Emergency Contact Person :
Whom can I thank for referring you?
Describe the reason you are bringing your child/adolescent for therapy:
Age
How does the child feel about seeing a therapist?
What are your goals for therapy?
Please read and sign below that you have read the following information:
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Although legally you have the right to examine your child’s records, therapy cannot be
effective if privacy is not respected. I value having parents actively participate in their
child’s therapy and will communicate regularly and openly with all parties while respecting
private information.
To legally provide consent for a child’s treatment, you must have sole or shared legal
custody of the child; by scheduling an appointment with me for a child under 18 years old
you are indicating that you have the legal right to consent to his or her treatment. If you do
not have sole or shared legal custody, you cannot consent to treatment.
If you have shared custody, your most current divorce decree must indicate that you can
make health care decisions without informing the other parent. If your custody
agreement states that you must inform the other parent, you could be in violation of
a court order if you fail to inform the other parent.
If you are currently involved in a separation, divorce or custody battle, please know that
my obligation is to provide therapy for your child, not to take sides in a custody dispute. In
most situations, it is best for all parents to be aware of and participate in the child’s
therapy. The more supportive each parent is to your child’s therapy, the better the longterm outcome for your child.
Printed name:
Signed name:
Kelli Underwood
Page 4
Kelli Underwood’s Policies
CONTACTING ME
 Due to my work schedule, I am often not immediately available by telephone. I
will not answer the phone when I am with a client, providing a training or
consultation.
 My telephone is answered by a voicemail that I do monitor frequently. You may
call my voicemail 24 hours a day and leave a message 919-355-6867. I will make
every effort to return your call on the same day you make it.
 When you leave me a message, please: always repeat your contact information,
even if you think I have it; state your name and return phone number clearly and
repeat it (it case it cuts out or is difficult to decipher); and be specific about what
your needs are and whether you need to hear back from me or not.
 I do not consistently check my email or voicemail from Friday afternoon until
Monday mornings.
 If you are difficult to reach, please inform me of some times when you will be
available and the best numbers to call. Please do not leave phone numbers for me
to return your call if you would not want me to identify myself to someone who
answered the phone (family member, roommate, etc.). When leaving a message I
will only state my name and ask you to return my call. I will not identify myself as
a counselor.
 Please know that if you need additional time to talk between sessions, it is best if
we can schedule this time, as trying to reach each other spontaneously can be
difficult.
 Extended phone time between sessions is sometimes unexpectedly needed during
treatment for a variety of reasons. I may need to bill for our phone time, if it is 25
minutes or longer, and this charge is typically not reimbursable by insurance.
 When leaving a message I will only state my name and ask you to return my call. I
will not identify myself as a counselor.
Kelli Underwood
Page 2
EMERGENCIES:
If you are unable to reach me and are experiencing a mental health crisis, you may:
1. Contact your primary care physician or another mental health
provider, i.e., psychiatrist if you have one.
2. Call a) the Hopeline at (919) 231-4525 or 800-844-7410 b)the Holly Hill
Hospital Respond Line at (919) 250-7000.
3. In the event of a life threatening emergency, call 911 or go to the nearest
emergency room.
*If you do experience an emergency and are unable to contact me, please notify me as
soon as possible as to the outcome
TERMINATION
Clients are under no obligation to continue services should they decide to terminate
at any time. However, I encourage you to have a conversation with me about a decision
to terminate prematurely. I will provide additional referrals and resources based on your
needs and goals.
PAYMENT: I am a fee for service practice. Payment is due at the time of each service.
I will provide invoices for submission to your insurance for reimbursement in your out of
network mental health benefits.
CANCELLATION POLICY: I agree to pay Kelli Underwood $50.00 by cash, credit
card or check when I do not give at least 24 hours advance notice for cancelling an
appointment or do not show for my appointment. Emergencies will be taken into
consideration when charging for missed appointments. I will inform of the charge.
I am responsible for paying these fees.
 Late Cancellation (Not providing 24 hour advance notice for the need to cancel.)
$50.00
 No-Show (Not showing up- failure to inform me you will not attend a scheduled
session.) $50.00 Please know that a policy such as this is
common practice
especially in the mental health profession. Thank you for your understanding, and
please feel to ask any questions about this policy.
HIPPAA
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your
Clinical Records and disclosures of protected health information. These rights include
requesting that we amend your record; requesting restrictions on what information from
your Clinical Records is disclosed to others; requesting an accounting of most disclosures
of protected health information that you have neither consented to nor authorized;
determining the location to which protected information disclosures are sent; having any
complaints you make about our policies and procedures recorded in your records; and the
right to a paper copy of this Agreement, the Notice form, and our privacy policies and
procedures.
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Purpose: The purpose of this notice is to explain to you how your protected health
information (PHI) may be used and disclosed for the purposes of treatment, billing, and
healthcare operations. It also provides you with information about how you may access
your PHI and ask to have restrictions placed on the information about you that may be
released without your authorization to another person or organization under the Health
Insurance Portability and Accountability Act (HIPAA) of 1996. If you have questions,
please feel free to ask.
II. With your Consent or Written Authorization: In most situations, I may only release
information about you with your written consent or authorization. An authorization is
written permission above and beyond the general consent that permits only specific
disclosures. Your PHI may be used for coordinating your healthcare with other mental
health providers or health care practitioners. For example, if you were also seeing a
psychiatrist, I would be allowed to release information about our work together that
would be relevant to the psychiatrist’s work with you. Please note that, except in the case
of emergency or if you are unable to give consent, I would first obtain your written
consent to make these disclosures. If you agree to share these records, you will need to
sign an authorization to release form. This form states exactly what information is to be
shared, with whom, and why, and it also sets time limits. You may read this form at any
time. You may revoke your authorization, which will be effective only after the date of
your written revocation.
III. Without your Consent or Written Authorization: Though the following situations
generally do not occur, the legal exceptions to confidentiality are as follows:
1. Court subpoena: If I am required by a judge/court of law to provide information from
our sessions necessary for “the proper administration of justice,” I can be required to
disclose information from your file. In rare instances, may records may subpoenaed for a
court procedure or I may be subpoenaed to testify in court. In these situations, I cannot
withhold information. I would, of course, discuss these types of exceptions with you
ahead of time.
2. Imminent danger to yourself or someone else. If you make a serious threat to harm
yourself or another person, the law requires me to notify the appropriate authorities to
keep you or others safe. This exceptions does not necessarily apply when people are
“feeling down or have experienced suicidal thoughts or aggressive/vindictive thoughts.
This exception is for situations where I believe you or someone else is in imminent
danger in the immediate future. I will take steps to keep you or others safe and will do
my best to discuss the matter with you before contacting others.
3. Abuse or neglect of a minor child or disabled adult. If I believe a child has been or
will be abused or neglected, or a disabled person is in a state of abuse, neglect, or
exploitation, I am legally required to report this to the appropriate authorities. Again, I
will do my best to discuss this with you before taking action.
4. Health information is required to be shared for the purpose of payment, treatment
or my operations: For example, if I need to disclose or submit billing information to your
insurance company. f it becomes necessary to contact an attorney or collection agency
for payment of fees, your name, identifying information about how to reach you, and the
amount of money you owe may be disclosed.
Note: For those under 18 years of age who are not emancipated from their
parents/guardians, North Carolina law does not provide the legal right to confidentiality.
Other potential situations: In addition, there may be times when I might consult about
part of our work with another mental health professional. This helps me to provide highquality services. These persons are also required to keep your information private and are
bound by HIPPAA and confidentiality practices with their licensures as well. Full
identifying information will not be given, and they will be told only as much as they need
to know to understand your situation for the purpose professional consultation or
supervision.
Except for the situations I have described above, I will always maintain your privacy. If
in the event that a disclosure or release of information is deemed necessary, I will make
every effort to fully discuss it with you before taking any action and will limit my
disclosure to only what is necessary.
I also ask you not to disclose the name or identity of any other client being seen in my
office.
IV. Records: Your personal mental health record, generated as a result of working with
me, will be retained for 7 years following your last therapy contact. After that time, it will
be destroyed by shredding to protect your confidentiality and privacy.
V. When HIPAA and State Laws Differ: When there is a discrepancy between HIPAA
mandates and mandates of North Carolina laws governing the practice of social work or
my ethical code of conduct, I will do my best to uphold the strictest form of
confidentiality and provide you with the maximum amount of protection for your private
health information.
VI. Client Rights:
1. Right to request restrictions. You may request limitations on your mental health
information that I may disclose, but I am not required to agree to your request. I
may decline if I feel it would affect your care. If I agree, I will comply with your
request unless the information is needed to provide you with emergency treatment.
2. Right to request confidential communications. You may request communications in
a certain way or at a certain location, but you must specify how or where you wish
to be contacted.
3. Right to inspect and copy. You have the right to inspect and/or copy your mental
health information used to make decisions about your care, for as long as the
record is maintained. I may charge a fee for copying, mailing, and supplies. Under
limited circumstances, your request may be denied. In some cases, however, you
may have this decision reviewed. On your request, I will discuss with you the
details of the request and denial process.
4. Right to amend. You have the right to request an amendment of PHI for as long as it is
maintained in the record. I have the right to deny your request, but I will explain
why in writing. We will discuss the details of this process together if needed.
5. Right to accounting of disclosures. You may request a list of the disclosures of your
mental health information for which you have neither provided consent or
authorization (as described earlier in this document). Upon your request, I will
discuss the details of this process with you.
6. Right to a copy of this Notice. You may request an additional paper copy of this
Notice at any time.
VII. Requirements regarding this notice: I am required to provide you with this Notice
that governs my privacy practices. I may change my policies or procedures in regard to
privacy practices. If and when changes occur, the changes will be effective for the PHI
that I have about you as well as any information I receive in the future. You may ask for
and receive a copy of the Notice that is in current effect at any time.
VIII. Complaints: I will take reasonable precautions to minimize risks, insure your
safety, and provide you with a positive experience. If at any time you believe that I have
not been diligent in performing my services, or you believe that your privacy rights have
been violated by me, please bring it to my attention so we can address the matter and
work to resolve it. I do appreciate an honest and open working relationship and
effectively meeting your needs is my goal. If there are concerns that we are not able to
resolve to your satisfaction, you do have the right to contact the North Carolina Social
Work Certification and Licensure Board at: NCSWCLB P.O. Box 1043 Asheboro, NC
27204
Email and Texting Policy
Email and text messages are not a HIPPAA-protected from of communication,
meaning that email is too vulnerable to intrusion to meet the standards required for
protected health information. Since email and texts are such a common and
convenient form of communication, I do offer email or texting as a way of contacting
me for non-urgent , non emergency communication (Please reference the form on
emergencies). I do not conduct therapy over email or text and my response time
may be inconsistent. Please note that my voice mail, email and text messages are
not necessarily checked during non -work hours, weekends, and holidays.
Yes, I would like to use email as a away to communicate.
No, I would prefer not to use email as a way to communicate.
Yes, I would like to use text as a way to communicate.
No, I would prefer not to use text as a way to communicate.
Client Signature:
Printed name:
Date:
Kelli Underwood, LCSW
Speaker, Consultant,
Psychotherapist
[email protected]
To Be Aligned, LLC
Your signature below indicates that you have
1.
2.
3.
4.
Read the Policies form and agree to its terms.
Read the HIPAA Notice of Privacy Practices.
Read the Fee for Service Statement.
Read the Late Cancellation/No-Show Policy and agree to its terms.
____________________________________ Printed Name of Client
____________________________________ Signature of Client
_____________________________________Date