madigans_therapy_paperwork.tex

\documentclass[12pt]{article}

\title{Madigan Kent, LCSW\\Intake Paperwork}
\date{}
\author{}

\newcommand{\signatureblock}{
  \begin{table}[!ht]
    \begin{tabularx}{\textwidth}{XlX}
      ~ & ~ & ~ \\
      ~ & ~ & ~ \\\cline{1-1}\cline{3-3}
      \small\textit{Client Signature} & ~ & \small\textit{Therapist Signature} \\
      ~ & ~ & ~ \\
      ~ & ~ & ~ \\\cline{1-1}\cline{3-3}
      \small\textit{Date} & ~ & \small\textit{Date} \\
    \end{tabularx}
  \end{table}
}

\usepackage{libertine,geometry,microtype,graphicx,tabularx,latexsym,multicol,enumitem}

\begin{document}

\maketitle

\section{Informed Consent \& Agreement for Services}

This document is intended to provide you important information regarding your
treatment. Please read it entirely and carefully and be sure to ask me any
questions you may have regarding its contents.

\subsection{Information about Your Therapist}

I am a Licensed Clinical Social Worker (LCSW). I received my BA from Columbia
University and my MSW from San Diego State University. I completed three years
of post-graduate training in Bioenergetic Analysis, a form of psychotherapy
that combines talk therapy with an understanding of the importance of the
body~-- and the energy that underlies both body and mind~-- in maintaining
psychological and emotional health. I have completed the three-year Somatic
Experiencing training program, focused on body-centered trauma treatment
interventions. I am also receiving ongoing training in Emotionally Focused
Therapy (EFT) for Couples. Please feel free to ask me questions regarding my
education, specializations, experience and professional orientation.

\subsection{Fees and Insurance}

My professional fee has already been discussed with you, as well as how
arrangements may be made for payment. A therapeutic hour is 54--60 minutes in
length and fees are payable at the time services are rendered.

\subsection{Confidentiality}

All communications between you and me will be held in strict confidence with
the following exceptions:

\begin{enumerate}
  \item You have signed an authorization allowing me to disclose information
  \item You are in present danger of harming yourself, or committing physical
    violence to another person
  \item You are in court ordered therapy; or your records are petitioned by the
    court
  \item There is an issue of child, elder, or dependent adult abuse
  \item	In addition, a federal law known as The Patriot Act of 2001 requires
    therapists (and others) in certain circumstances, to provide FBI agents
    with books, records, papers, documents and other items and prohibits the
    therapist from disclosing to the patient that the FBI sought or obtained
    the items under the Act.
\end{enumerate}

If you participate in marital or family therapy, I will not disclose
confidential information about your treatment unless all person(s) who
participated in the treatment with you provide their written authorization to
release. (In addition, I will not disclose information communicated privately
to me by one family member, to any other family member without written
permission.)

\subsection{Appointment Scheduling and Cancellation Policies}

Sessions are typically scheduled to occur one time per week at the same time
and day if possible. Sometimes, I may suggest a different amount of therapy
depending on the nature and severity of your concerns. Your consistent
attendance greatly contributes to a successful outcome. In order to cancel or
reschedule an appointment, I would appreciate the courtesy of twenty-four hours
notice; otherwise you will be charged your customary fee for that session,
barring emergencies of course. If you are using insurance and cancel without
notice, you will be charged the full insurance fee, not just the co-pay.

\subsection{Therapist Availability/Emergencies/General Policies}

I would be happy to respond to any questions or needs you may have in between
visits and during my normal working hours. However, I will attempt to keep
these contacts brief as most important issues are better addressed within the
context of a regular face-to-face session. I check my voicemail several times
throughout the day and will return your call as soon as possible. However, if
you should have a mental health emergency and are unable to reach me, please
call 911.

\subsection{About the Therapy Process}

It is my intention to provide services that will assist you in reaching your
goals. Based upon the information you share, I will provide recommendations to
you regarding your treatment and you have the right to agree or disagree with
my recommendations. I believe that therapists and clients are partners in the
therapeutic process. Periodically, I will provide feedback to you regarding
your progress and invite your participation in this discussion. Due to the
varying nature and severity of problems and the individuality of each patient,
I am unable to predict the length of your therapy or to guarantee a specific
outcome or result.

\subsection{Termination of Therapy}

The length of your treatment and the timing of the eventual termination of your
treatment depend on the specifics of your treatment plan and the progress you
achieve. It is a good idea to plan for your termination, in collaboration with
me. We will discuss a plan for termination as you approach the completion of
your treatment goals.

You may discontinue therapy at any time. If you or I determine that you are not
benefiting from treatment, either of us may elect to initiate a discussion of
your treatment alternatives. These alternatives may include, among other
possibilities, referrals, changing your treatment plan, or terminating your
therapy.

Your signature indicates that you have read this agreement carefully and
understand its contents. Please ask me to address any questions or concerns
that you have about this information before you sign!

\signatureblock

\pagebreak

\section{Notice of Privacy Practices and Client Rights}

This notice describes how treatment information about you may be used and
disclosed and how you can get access to this information and your rights as a
client. Please review it carefully. Madigan Kent, LCSW, has been and will
always be totally committed to maintaining clients’ confidentiality. I will
only release healthcare information about you in accordance with federal and
state laws and ethics of the social work profession.

\subsection{Right to Privacy}

Health care providers are required by federal and state law to maintain the
privacy of your treatment information. We are also required to give you notice
about our privacy practices, our legal duties, and your rights concerning your
treatment information. I must follow the privacy practices that are described
while they are in effect (they went into effect April 14, 2003). I reserve the
right to change my privacy practices and the terms of this notice at any time,
provided such changes are permitted by applicable law. You may request a copy
of the notice at any time from me.

\subsection{Use and Disclosures of Treatment Information}

I will use information about your health care to provide you with treatment, to
arrange payment for my services, and in conjunction with other health care
providers, organizations, and professionals. The information privacy practices
in this notice will be followed by any associate involved in your care and any
business associate with whom I share health information.

Use and disclosure of your health information is for the purpose of providing
services. Providing treatment services, collecting payment and conducting
healthcare operation are necessary activities for quality care. State and
federal laws allow me to use and disclose your health information for these
purposes:

\paragraph{For treatment.} I may need to use or disclose health information
about you to provide, manage, or coordinate your care or related services. This
could include consultants and potential referral sources.

\paragraph{For payment.} I may use and disclose your treatment information to
obtain payment for services I provide you, including~-- but not limited
to~-- verifying insurance coverage and/or benefits with your insurance carrier, to
process your claims as well as information needed in connection with billing
and collection activities. I may bill the person in you family who pays for
your insurance.

\paragraph{Healthcare operations.} I may need to use information about you to
review our treatment procedures and business activity. Information may be use
for certification, compliance and licensing activities.

\paragraph{Scheduling appointments.} I may use your phone numbers to call you
and leave messages to schedule or remind you of appointments.

\paragraph{Legal proceedings.} I may disclose information in response to a court
or administrative order, subpoena, discovery request, or other lawful process
under certain circumstances.

\subsection{Other Uses or Disclosures of Your Information Which Do Not Require
Consent}

There are some instances where we may be required to use and disclose
information without your consent. I am mandated by Illinois State Law to report
any information reported to me regarding any physical or sexual abuse of a
minor or elder. This information will be reported to Department of Children and
Family Services as well as other appropriate authorities.

I may also disclose information to appropriate authorities if I reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence
or the possible victim of other crimes. I may disclose information to the
extent necessary to protect your health or safety, or the health or safety of
others. I may also share information with law enforcement if a crime is
committed on the office premises or against myself or as required by law.

I will not disclose your treatment information if that disclosure is prohibited
or significantly limited by other applicable law.

\subsection{Your Client Rights}

\paragraph{You have right to request how we contact you.}

It is my normal practice to communicate with you about health matters such as
appointment reminders, etc. at your home address and daytime phone number you
gave when you scheduled your appointment. Sometimes I may leave messages on
your voicemail. You have the right to request that I communicate with you in a
different way.

\begin{table}
  \begin{tabular}{lp{0.5\textwidth}}
    May I contact you at home? & ~ \\\cline{2-2}
    May I contact you at work? & ~ \\\cline{2-2}
    May I contact you by cell phone? & ~ \\\cline{2-2}
    Where may I contact you? & ~ \\\cline{2-2}
  \end{tabular}
\end{table}

\paragraph{You have the right to release you treatment records.}

You may consent in writing to release your records to others. You have the
right to revoke this authorization, in writing, at any time. However, a
revocation is not valid to the extent that I have acted in reliance on such
authorization.

\paragraph{You have the right to inspect and copy your treatment and billing
records.} You have the right to inspect and obtain a cop of your information
contained in my treatment records. To request access to your billing or health
information, you must make a request in writing by sending a letter to me at
the address above. Under limited circumstances, I may deny your request to
inspect and copy. If you request a copy of any information, I may charge a
reasonable fee for the costs of copying, mailing, and supplies.


\paragraph{You have the right to add information or amend your treatment
records.} If you feel that information contained in you treatment record is
incorrect or incomplete, you may request me to add information to amend the
record with an explanation of why the information should be changed. I will
make a decision on your request within 60 days. Under certain circumstances, I
may deny your request to add or amend information. If I deny your request, you
have a right to file a statement that you disagree. Your statement and my
response will be added to your record. To request an amendment, you must make
your request in writing by sending a letter to me at the address above.

\paragraph{You have the right to an accounting of disclosures.} You have the
right to receive a list of instances in which I disclosed your information for
purposes other than treatment, payment, or those disclosures you have
authorized in writing, such as, if any, child or elder abuse, disclosures
related to suicidal or homicidal threats, and disclosures to the U.S. Dept of
Human Services to evaluate compliance.

\paragraph{You have the right to request restrictions on uses and disclosures
of your health.} You have the right to request restrictions on uses and
disclosures of your treatment information for the purposes of treatment,
payment, or healthcare operations. You request must be submitted in writing to
the address listed above. I am not required to allow your request. If I do
agree with the request, I will comply with it except to the extent that
disclosure has already occurred or if you are in need of emergency treatment
and the information is needed to provide that treatment.

\paragraph{You have the right to receive changes in policy.} You have the right
to receive upon request any future policy changes secondary to changes in state
and federal laws.

\subsection{Questions \& Complaints}

If you have any questions about this notice or have concerns about your privacy
rights, it is my sincere hope that you will feel comfortable sharing them with
me.

If you believe your privacy rights have been violated and wish to file a
written complaint with Madigan Kent Therapy, please include as much detail as
possible and send it to Madigan Kent, LCSW, 1224 W. Lawrence Ave, Suite 218,
Chicago, IL 60625. You may also send a written complaint to the Secretary of
the US Department of Health and Human Services 200 Independence Avenue, S.W.
Washington, D.C. 20201 or by calling (202) 619-0257.

\subsection{Acknowledgement of Receipt of Notice of Privacy Practices}

By signing this form, you acknowledge that you have received the Notice of
Privacy Practices from Madigan Kent, LCSW. This notice provides information
about the ways in which I This notice provides information about the ways in
which I may use and disclose your protected health information. I encourage you
to read it in full. The Notice of Privacy Practices is subject to change. You
may ask me at any time for a copy of the current notice, either in person or by
contacting me at the number or addresses above.

I acknowledge that I have received the Notice of Privacy Practices.

\signatureblock

\pagebreak

\section{Symptoms and Goals}

\subsection{Symptoms checklist}

\textsc{Please circle all that apply.}

\begin{multicols}{2}
  \begin{itemize}[noitemsep]
    \item[] $\Box$\hspace{0.5em}Angry or irritable feelings
    \item[] $\Box$\hspace{0.5em}Loss of Interest
    \item[] $\Box$\hspace{0.5em}Hopelessness
    \item[] $\Box$\hspace{0.5em}Crying spells
    \item[] $\Box$\hspace{0.5em}Difficulty making decisions
    \item[] $\Box$\hspace{0.5em}Depression
    \item[] $\Box$\hspace{0.5em}Suicidal thoughts
    \item[] $\Box$\hspace{0.5em}Sleep difficulties
    \item[] $\Box$\hspace{0.5em}Impulses to hurt self or others
    \item[] $\Box$\hspace{0.5em}Nightmares
    \item[] $\Box$\hspace{0.5em}Feeling that nothing mattered
    \item[] $\Box$\hspace{0.5em}Anxiety or nervousness
    \item[] $\Box$\hspace{0.5em}Violent behavior
    \item[] $\Box$\hspace{0.5em}Memory loss
  \end{itemize}
\end{multicols}

\vspace{1em}

\begin{multicols}{2}
  \begin{itemize}[noitemsep]
    \item[] $\Box$\hspace{0.5em}Panicky feelings
    \item[] $\Box$\hspace{0.5em}Fears of particular situations
    \item[] $\Box$\hspace{0.5em}Avoidance of social situations
    \item[] $\Box$\hspace{0.5em}Weakness
    \item[] $\Box$\hspace{0.5em}Fainting spells
    \item[] $\Box$\hspace{0.5em}Mood swings
    \item[] $\Box$\hspace{0.5em}Disorientation
    \item[] $\Box$\hspace{0.5em}Obsessive preoccupations
    \item[] $\Box$\hspace{0.5em}Repeated thoughts
    \item[] $\Box$\hspace{0.5em}Compulsive behaviors
    \item[] $\Box$\hspace{0.5em}Easily distracted
    \item[] $\Box$\hspace{0.5em}Feel that you may lose control
  \end{itemize}
\end{multicols}

\vspace{1em}

\begin{multicols}{2}
  \begin{itemize}[noitemsep]
    \item[] $\Box$\hspace{0.5em}Paranoid feelings
    \item[] $\Box$\hspace{0.5em}Elevated mood or euphoria
    \item[] $\Box$\hspace{0.5em}Too much energy
    \item[] $\Box$\hspace{0.5em}Can’t stop talking
    \item[] $\Box$\hspace{0.5em}Racing thoughts
    \item[] $\Box$\hspace{0.5em}Inability to talk
    \item[] $\Box$\hspace{0.5em}Suspiciousness
    \item[] $\Box$\hspace{0.5em}Believe your thoughts are controlled
    \item[] $\Box$\hspace{0.5em}Fear others
    \item[] $\Box$\hspace{0.5em}Visual or auditory hallucinations
    \item[] $\Box$\hspace{0.5em}Confusion
    \item[] $\Box$\hspace{0.5em}Disorganized thoughts
    \item[] $\Box$\hspace{0.5em}Self-critical
    \item[] $\Box$\hspace{0.5em}Feel more important than others
    \item[] $\Box$\hspace{0.5em}Hear voices when no one is there
    \item[] $\Box$\hspace{0.5em}See things that aren't there
    \item[] $\Box$\hspace{0.5em}Transmit your thoughts to others without speaking
    \item[] $\Box$\hspace{0.5em}Hear your thoughts out loud
  \end{itemize}
\end{multicols}

\vspace{1em}

\begin{multicols}{2}
  \begin{itemize}[noitemsep]
    \item[] $\Box$\hspace{0.5em}Difficulty following rules
    \item[] $\Box$\hspace{0.5em}Difficulty feeling warm to others
    \item[] $\Box$\hspace{0.5em}Wanting or letting everyone do things for you
    \item[] $\Box$\hspace{0.5em}Avoiding responsibilities
    \item[] $\Box$\hspace{0.5em}Difficulty trusting others
    \item[] $\Box$\hspace{0.5em}Not getting along with people
    \item[] $\Box$\hspace{0.5em}Trying to be perfect
    \item[] $\Box$\hspace{0.5em}Selfishness
    \item[] $\Box$\hspace{0.5em}Being overly sensitive
    \item[] $\Box$\hspace{0.5em}Use others for personal gain
  \end{itemize}
\end{multicols}


\vspace{1em}

\begin{multicols}{2}
  \begin{itemize}[noitemsep]
    \item[] $\Box$\hspace{0.5em}Nausea/vomiting
    \item[] $\Box$\hspace{0.5em}Excessive concern over a physical problem
    \item[] $\Box$\hspace{0.5em}Headaches
    \item[] $\Box$\hspace{0.5em}Seizures
    \item[] $\Box$\hspace{0.5em}Shortness of breath
    \item[] $\Box$\hspace{0.5em}Medical problems
    \item[] $\Box$\hspace{0.5em}Drug use or addiction
    \item[] $\Box$\hspace{0.5em}Anorexia (not eating)
    \item[] $\Box$\hspace{0.5em}Cheating or stealing
    \item[] $\Box$\hspace{0.5em}Exaggerating physical problems
    \item[] $\Box$\hspace{0.5em}Exaggerating emotional problems
    \item[] $\Box$\hspace{0.5em}Recent weight gain (how much?)
    \item[] $\Box$\hspace{0.5em}Recent weight loss (how much?)
    \item[] $\Box$\hspace{0.5em}Lack of energy
    \item[] $\Box$\hspace{0.5em}Use of alcohol
    \item[] $\Box$\hspace{0.5em}Bulimia (gorging then vomiting)
    \item[] $\Box$\hspace{0.5em}Physically abusing yourself
  \end{itemize}
\end{multicols}

\subsection{Desired results}

What are your goals for therapy?

\vspace{-1em}

\begin{table}[!ht]
  \begin{tabularx}{\textwidth}{X}
    ~ \\ \hline
    ~ \\ \hline
    ~ \\ \hline
    ~ \\ \hline
  \end{tabularx}
\end{table}

\pagebreak

\section{Authorization to Obtain/Release Information}

I, \rule{5em}{0.5pt} hereby authorize Madigan Kent, Licensed Clinical Social
Worker, to release/obtain information to/from:

\begin{table}[!ht]
  \begin{tabularx}{\textwidth}{XXX}
    ~ & ~ & ~ \\
    ~ & ~ & ~ \\ \hline
    \small\textit{Name} & ~ & ~ \\
    ~ & ~ & ~ \\
    ~ & ~ & ~ \\ \hline
    \small\textit{Address} & ~ & ~ \\
    ~ & ~ & ~ \\
    ~ & ~ & ~ \\ \hline
    \small\textit{City} & \small\textit{State} & \small\textit{Zip} \\
    ~ & ~ & ~ \\
    ~ & ~ & ~ \\ \hline
    \small\textit{Phone} & ~ & ~ \\
  \end{tabularx}
\end{table}

\noindent This information will be released for the purpose of case
consultation and/or \rule{10em}{0.5pt}.

I understand that I may revoke this consent to release/obtain information at
any time, except to the extent that action has already been taken for the
purpose(s) specified above.

This consent will be valid from \rule{10em}{0.5pt} to \rule{10em}{0.5pt}. You
may receive a copy of this authorization upon request.

\signatureblock

\pagebreak

\section{Authorization Release for Permission to Record and for Use of Recorded Material}

Video and audio recording are commonly used for consultation, training and
research in couple therapy. In order to record your session I need your written
consent. The recording of sessions will likely enhance the effectiveness of
your treatment, but is not required. You may decline to have sessions recorded.

\paragraph{Confidentiality.} For any of the uses agreed to below, the strictest
confidentiality will be maintained, and there will be no sharing of the
recorded material beyond the limits specified below. Except for your first
names and your voice and/or image on the recordings, there will be no
information that could identify you. The recording will never knowingly be
shared with anyone who knows you. Mental health professionals who may view or
hear recorded material of your session (if permission is given here) are bound
by law and by code of ethics to the same obligation to protect your
confidentiality. Except as noted below, the existence of this recording will
not be discussed with anyone at any time.

\begin{table}[!ht]
  \begin{tabularx}{\textwidth}{|l|l|X|}
    \hline
    Video \& Audio & Audio Only & How the recorded material may be used \\\hline
    ~ & ~ & \textsc{Session Review Only.}\hspace{0.5em} The recording may be reviewed privately by Madigan Kent prior to the subsequent session. IT will not be kept beyond the subsequent session and no recording will be kept beyond the conclusion of treatment. \\\hline
    ~ & ~ & \textsc{Consultation.}\hspace{0.5em} The recording may be shared with the clinical consultant who has been engaged to provide expert clinical consultation regarding the therapy process. The consultation is a vital source of professional development and accountability; it provides additional clinical expertise as a resource to your treatment and increases its effectiveness. \\\hline
    ~ & ~ & \textsc{Training.}\hspace{0.5em} A brief recording excerpt may be used by Madigan Kent in the training of couple therapists to demonstrate concepts and techniques of treatment. No information, which could identify you, beyond the content of the tape, will be shared. \\\hline
  \end{tabularx}
\end{table}

\paragraph{Other Conditions (specify).}

~\vspace{3em}

\paragraph{Freedom to withdraw consent} We understand that we may withdraw
previously granted consent at any time without giving a reason, and that this
will not affect our treatment or relationship with our therapist in any way.

We give our permission to Madigan Kent, LCSW to video/audio (circle one) record
our couple therapy sessions for the purposes indicated above.

\signatureblock

\pagebreak

% \section{Client Information Form}

% \begin{table}[!h]
%   \begin{tabularx}{\textwidth}{XXXXXXXXXXXX}
%     Date & \multicolumn{5}{l}{~} & SSN & \multicolumn{5}{l}{~} \\\cline{2-6}\cline{8-12}
%     \multicolumn{7}{l}{~} & \multicolumn{5}{c}{\small\textit{(Insurance only)}} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\\cline{1-12}
%     \multicolumn{4}{c}{Name} & \multicolumn{4}{c}{Birth Date} & \multicolumn{4}{c}{Age} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     \multicolumn{2}{l}{Home Address} & \multicolumn{10}{l}{~}  \\\cline{3-12}
%                                      & & & \multicolumn{3}{c}{Street} & \multicolumn{3}{c}{City} & \multicolumn{3}{c}{Zip Code} \\
%                                      & & & & & & & & & & & \\
%                                      & & & & & & & & & & & \\\cline{1-12}
%     \multicolumn{4}{c}{Home Ph \#} & \multicolumn{4}{c}{Work Ph \#} & \multicolumn{4}{c}{Other} \\
%                                    & & & & & & & & & & & \\
%     \multicolumn{2}{l}{Marital Status:} & \multicolumn{2}{c}{Single\hspace{1em}\Box} & \multicolumn{2}{c}{Married\hspace{1em}\Box} & \multicolumn{2}{c}{Separated/Divorced\hspace{1em}\Box} & \multicolumn{2}{c}{Widowed\hspace{1em}\Box} & \multicolumn{2}{c}{Live-In\hspace{1em}\Box} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     \multicolumn{2}{l}{Employer} & \multicolumn{10}{l}{~} \\\cline{3-12}
%     \multicolumn{3}{l}{~} & \multicolumn{3}{c}{Name of Company} & \multicolumn{3}{c}{Address} & \multicolumn{3}{c}{Phone} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     \multicolumn{2}{l}{Referred by} & \multicolumn{10}{l}{~} \\\cline{3-12}
%                                     & \multicolumn{11}{c}{Source/Name} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     \multicolumn{2}{l}{Emergency Contact} & \multicolumn{10}{l}{~} \\\cline{3-12}
%     \multicolumn{2}{l}{~} & \multicolumn{2}{c}{name} & \multicolumn{4}{c}{address} & \multicolumn{2}{l}{phone} & \multicolumn{2}{l}{relationship} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     \multicolumn{2}{l}{Insurance} & \multicolumn{10}{l}{~} \\\cline{3-12}
%     \multicolumn{3}{l}{~} & \multicolumn{3}{c}{Name} & \multicolumn{3}{c}{Policy \#} & \multicolumn{3}{c}{Insured's name} \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ & ~ \\
%     \multicolumn{3}{l}{Insurance Billing Address} & \multicolumn{9}{l}{~} \\\cline{4-12}
%     \multicolumn{3}{l}{~} & \multicolumn{3}{c}{City} & \multicolumn{3}{c}{State} & \multicolumn{3}{c}{Provider Phone \#}
%   \end{tabularx}
% \end{table}

\subsection{Treatment History}

\begin{enumerate}
  \item Have you ever seen a mental health professional? If so, please
    describe: who, when, and for what problem.\vspace{5em}
  \item Please
    describe any psychiatric hospitalizations: when, where, and for what
    problem.\vspace{5em}
\end{enumerate}

\subsection{Childhood History}

\begin{enumerate}
  \item Where did you grow up?\vspace{3em}
  \item Did you move often? If so, how
    many times would you estimate you moved before leaving home?\vspace{3em}
  \item How old were you when you moved away from home, and what were the
    circumstances?\vspace{3em}
  \item Who raised you? Please describe if it was someone other than your parents.\vspace{3em}
  \item Describe your parents' personalities
    \begin{enumerate}
      \item Mother\vspace{3em}
      \item Father\vspace{3em}
    \end{enumerate}
  \item How did your parents treat you?
    \begin{enumerate}
      \item Mother\vspace{3em}
      \item Father\vspace{3em}
    \end{enumerate}
  \item Describe your parents' marriage.\vspace{3em}
  \item Circle all of the following circumstances that apply to your parents.
    \begin{enumerate}
      \item Separation
      \item Multiple separations
      \item Divorce
      \item Domestic violence
      \item Mother's remarriage (how many times?)
      \item Father's remarriage (how many times?)
    \end{enumerate}
  \item What are/were your parents' occupations?
    \begin{enumerate}
      \item Mother\vspace{3em}
      \item Father\vspace{3em}
    \end{enumerate}
  \item List your siblings and their ages relative to yours.\vspace{3em}
  \item What level of schooling did you complete?\vspace{3em}
\end{enumerate}

\subsection{Substance Use}
\begin{enumerate}
  \item Have you ever used street drugs? If so, please name them and at what
    age you started.\vspace{3em}
  \item Have you had any problems with these drugs?\vspace{3em}
  \item How much alcohol do you drink? Please name what, how much and how
    often.\vspace{3em}
  \item Do you smoke tobacco? If so, how much?\vspace{3em}
\end{enumerate}

\subsection{General Health}
\begin{enumerate}
  \item Do you have chronic tension in your body? If so, please describe.\vspace{3em}
  \item Do you have frequent headaches? If so, have you received a medical
    explanation for them?\vspace{3em}
  \item What if any physical exercise do you regularly do? Please describe.\vspace{3em}
  \item Have you had any traumatic experiences or serious accidents? If so, please describe.\vspace{3em}
  \item Have you had any major diseases? If so, please describe.\vspace{3em}
  \item Have you had any major surgeries? If so, please describe.\vspace{3em}
  \item What if any prescription medicines do you take?\vspace{3em}
  \item What if any non-prescription medicines, herbs, or other supplements do you take?\vspace{3em}
\end{enumerate}

\subsection{Incomplete Sentences}

Please complete the following sentences:

\begin{enumerate}
  \item I like
  \item The happiest time
  \item I want to know
  \item Back home
  \item I regret
  \item At bedtime
  \item Men
  \item The best
  \item What annoys me
  \item People
  \item A mother
  \item I feel
  \item My greatest fear
  \item In high school
  \item I can't
  \item Sports
  \item When I was a child
  \item My nerves
  \item Other people
  \item I suffer
  \item I failed
  \item The future
  \item My mind
  \item Reading
  \item I need
  \item Marriage
  \item I am best when
  \item Sometimes
  \item What pains me
  \item I have
  \item This place
  \item I am very
  \item The only trouble
  \item I wish
  \item My father
  \item I secretly
  \item I
  \item Dancing
  \item My greatest worry is
  \item Most women
\end{enumerate}

\pagebreak

\end{document}