Kendall Wagner, MFT #31553 P.O. Box 1701, Carlsbad, Ca 92018-1701
Client Intake Form Date-____/_____/________
Date of Birth_____/_______/_________
Name__________________________________ phone HM_______________________
Address________________________________ CELL______________________
_______________________________________ Emergency Contact_________________
_______________________________________ Number__________________________
List current marriage or significant relationship:______________________________________________
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List Children and ages:______________________ ______________________ __________________
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List past marriages/divorces and how ended:___________________________________________________
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List past therapists, dates of treatment and reason for termination::
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List current or past psychiatrists and medications taken for an emotional condition.
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Please list past and current alcohol and drug use.
Drug_____________________ amount____________________________ Current use_______________
Drug_____________________ amount____________________________ Current use_______________
Drug_____________________ amount____________________________ Current use_______________
List all physical/sexual/emotional(verbal) abuse and assaults(violent crimes) your age and by whom:
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List parents/siblings. Include their current age/deceased and description of the relationship:
Mother:______________________________________________________________________________
Father:_______________________________________________________________________________
Siblings:______________________________________________________________________________
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Why are you here today. Please list as much information as possible. Please take as much room as you need to share any information or history that you feel I should know.
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Open for your use.
I,________________________________________, consent to enter into psychotherapy with Kendall Wagner, MFT. I understand that all sessions are private and confidential. There are 5 areas where I understand that my confidentiality will be waived and I release Kendall Wagner, MFT from any liability in the following situations.
1. Any and all issues (past and present) of elder and/or child abuse of any kind.
2.Any significant threat made to an identifiable third party.
3.If I am considering suicide, if I am considered a threat to myself.
4.If the therapist receives a subpoena for records and I make no objections, or if mandated by the court.
5.If I sign a release or if I make a complaint against the therapist. The therapist may use any and all information to defend themselves.
The Sixth area: Carlsbad Counseling Center and Kendall Wagner,MFT will do all possible to protect my online content. But I understand that the internet is not full proof and I will not hold CCC or K. Wagner,MFT for any lapse of security by outside intruders to the internet.
I waive my right to see my actual file. I do agree to accept a written summary of services provided upon a written request. Summary charges are 20.00 per request. Also I understand that after 5 years the therapist may and will purge my file according to the legal and ethical practices set forth by the BBS and CAMFT.
All internet sessions are based on 15 minute blocks for a fee of _15________. All cancellations without 48 hour notice will be charged the full fee. Extended phone consultations will be charged in 15 min. increments. Due and payable at the next session. All payments will be via check and sent to:
Kendall Wagner,MFT
P.O. Box 1701
Carlsbad, Ca. 92018-1701
I have fully read and understand the full contract and consent for psychotherapy.
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Name Date