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Mindful Therapy Group2171 Jericho Tpke.Suite 240Commack, NY 11725(631) 486-7788 Office hours by appointmentFor Your InformationYour right to know:Counselors practicing counseling for a fee must be registered or licensed with thedepartment of health for the protection of the public health and safety.Registration or licensure of an individual with the department does notinclude recognition of any practice standards, nor necessarily implies theeffectiveness of any treatment.Appointments:Making and keeping appointments is important to the therapeutic process. If it isnecessary to cancel an appointment, please give 24 hours notice in order to avoidbeing charged for the session. Since I am unable to use this time for anotherclient, please note that you will be billed for the entire cost of your scheduledappointment if it is not timely cancelled, unless such cancellation is due toillness or an emergency. We appreciate your help in keeping the office schedulerunning timely and efficiently.Confidentiality:What you discuss during your therapy session is kept confidential. No contents ofthe therapy sessions, whether verbal or written may be shared with another partywithout your written consent or the written consent of your legal guardian. Thefollowing is a list of exceptions:Duty to Warn & Protect:If you disclose a plan to threat or harm yourself, the therapist mustattempt to notify your family and notify legal authorities. In addition, ifyou disclose that you plan to threat or harm another person, the therapistis required to warn the possible victim and notify legal authorities.Abuse of Children & Vulnerable Adults:If you disclose or it is suspected that there is abuse or harmful neglect ofchildren or vulnerable adults (elderly, disabled/incompetent) the therapistmust report this information to the appropriate state agency and/or legalauthorities.Prenatal Exposure of Controlled Substances:Therapists must report any admitted prenatal exposure to controlledsubstances that could be harmful to the mother or the child.Insurance Providers:Insurance companies and other third party payers are given information thatthey require regarding services to the clients. The types of informationthat may be requested includes: types of service, dates/times of service,diagnosis, treatment plan, progress of therapy, case notes, summaries, etc.

Emergencies & Non-scheduled Contact:We cannot guarantee that we will be available in emergencies. There is a 24-hourcrisis line available on Long Island at (516) 679-1111. CPEP is the PsychiatricEmergency Room at Stonybrook University Hospital and can be reached at 631-4446050.Client Rights and Responsibilities:Clients have the right to request a change of therapy, referral to anothertherapist, or to discontinue therapy, or other referral sources. It is theclient’s responsibility to choose the therapist and treatment modality which bestsuits their needs.By signing this document you are giving your permission for me to release theinformation that they require. You are responsible for paying any of my fees thatyour insurance doesn’t cover, and for notifying me of any changes in insurancecoverage that may affect my services.Fees: The fee is 150 for an individual session and is 200 for a couple/familysession. We are sometimes able to slide the fee down if needed.Payment:Payment is expected at the time of service (cash or check only) unless otherarrangements are made.We understand that payment is to be made at each session unless other arrangementshave been made. Telephone appointments are billed at the same rate as officesessions. Payment for telephone appointments must be made within 15 days, or atthe next scheduled appointment, whichever comes first. We also understand that wewill be billed 20.00 for checks returned for insufficient funds.I have read and understand the information contained in this document, and I agreeto participate in and receive, and/or have my child(ren) participate in andreceive counseling from Mindful Therapy, LCSW, PLLC This agreement shall remainin effect until either the client or the therapist, or both terminate treatment.Client:date:date:Mindful Therapy Clinician

Client Intake FormToday’s Date:Your Name:Parent/Legal Guardian (if under 18):Referred by:Your Residential Address (include zip code):You’re Mailing Address – with zip code (if different):Your Phone #’s:Home:Work:Cell:Is it okay to leave message on machine?yesnoWith people there?yesnoIs it okay to leave message on machine?yesnoWith people there?yesnoIs it okay to leave message on machine?yesnoWith people there?yesnoYour e-mail address(s):*Please note email correspondence is not considered to be a confidential medium ofcommunication.Your birth date:Your Social Security #:Emergency contact person:Relationship:Phone #’s:Insurance Information:Insurance Company:Address:Phone:

Please take some time and fill out this form thoughtfully. The information will be confidential. If youare uncomfortable answering any of the questions or some do not apply, feel free to skip them. Thankyou.Marital Status:MarriedWidowedDivorcedNever MarriedDomestic PartnershipParental Status:No ChildrenHave ChildrenHow many:Ages:Living Situation:Live AloneLives with familyOther (please specify):Your Occupation(s):Your employer(s):School:Years of education:Your physician:When was your last visit to the doctor?Your current health status, concerns or problems, disability, etc.:Your current medications:Have you ever been prescribed psychiatric medication?If yes, please list and provide dates:Have you previously received any type of mental health services (psychotherapy,psychiatric services, couples/family counseling)?Please provide the names of previous practitioners:

Ethnicity, cultural, religious background, sexual orientation & gender identitythat you want me to know about:Is there domestic violence, physical abuse, sexual abuse, emotional abuse, neglect,substance abuse, or mental illness in your present living situation or family ofchoice?Is there other important information about your present living situation or familyof choice I should know?How would you describe your current sleeping habits?How many hours a week and what type of exercise do you do?Are you comfortable with your present weight? Are you on a special diet? Pleasedescribe.Have you experienced the death of friend(s) or close family member(s)? If yes, whoand when?Have you ever considered or attempted suicide? If yes, when, method(s) and thecircumstances?Have you considered harming yourself since then?Please describe any fears, worries or anxieties that are particularly problematicfor you.

Have you or anyone close to you ever been concerned about your alcohol or drug use?If yes, please explain.Are you currently in a romantic relationship?If yes, for how long?On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would yourate your relationship?What do you consider to be some of your strengths?What do you consider to be some of your weaknesses?What specific issues do you want to work on in therapy?In the section below, please identify if there is a family history of any of thefollowing. If yes, please indicate the family member’s relationship to you in thespace provided (e.g. father, grandmother, brother, etc.)CircleList Family memberAlcohol/Substance Abuseyes/noAnxietyyes/noBipolar Disorderyes/noDepressionyes/noDomestic Violenceyes/noEating Disorderyes/noObsessive Compulsive Disorderyes/noSchizophreniayes/noSuicideyes/no

Patient Responsibility Form1. Individual’s Financial ResponsibilityI understand that I am financially responsible for my health insurance deductible, coinsuranceor non-covered service.Co-payments are due at time of serviceIn the event that my health plan determines a service to be “not payable” I will be responsiblefor the complete charge and agree to pay the costs of all services provided2. Insurance Authorization for Assignment of BenefitsI hereby authorize and direct payment for my medical benefits to Mindful Therapy LCSW,PLLC on my behalf for any services furnished to me in her office3. Authorization to Release RecordsI hereby authorize Mindful Therapy LCSW, PLLC to release to my insurer, governmentalagencies or any other entity financially responsible for my medical care, all information,including diagnosis and the records of any treatment rendered to me needed to substantiatepayment for such medical services as well as information required for precertification,authorization or referral to other medical provider.Signature of Client or Responsible PartyPrint Name of Client or Responsible Party/Relationship to ClientDateDate

Mindful Therapy, LCSW, PLLC2171 Jericho Tpke.Suite 240Commack, NY 11725631-486-7788Consent to the Use and Disclosure of Health Informationfor Treatment, Payment, or Healthcare OperationsI understand that as part of my mental health treatment, Mindful Therapy LCSW, PLLC, originates andmaintains health records describing my health history, symptoms, diagnoses, treatment, and anyplans for future care or treatment. I understand that this information serves as: a basis for planning my care and treatmenta means by which a third-party payer can verify that services billed were actually providedI understand and have been provided with a Notice of Information Practices that provides a morecomplete description of information uses and disclosures. I understand that I have the right to reviewthe notice prior to signing this consent. I understand that Mindful Therapy reserves the right to changeher notice and practices and prior to implementation will mail a copy of any revised notice to theaddress I’ve provided. I understand that I have the right to object to the use of my mental healthinformation for directory purposes. I understand that I have the right to request restrictions as to howmy mental health information may be used or disclosed to carry out treatment, payment, or healthcareoperations and that the organization is not required to agree to the restrictions requested. Iunderstand that I may revoke this consent in writing, except to the extent that Jill Kofler has alreadytaken action in reliance thereon.I request the following restrictions to the use or disclosure of my mental health information:Signature of Patient or Legal Representative WitnessDate Notice Effective Date or VersionAccepted DeniedSignatureDate:

Mindful Therapy Group 2171 Jericho Tpke. Suite 240 Commack, NY 11725 (631) 486-7788 Office hours by appointment For Your Information . therapist, or to discontinue therapy, or other referral s