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Everything you discuss on this form, or in the future with an NCC therapist, will be kept confidential and stored only in locked locations. Your privacy is important to us, but we are also trying to make sure that our services are a good fit for you. Please also know that legally there are a few situations in which therapists are mandated by law to break confidentiality: those being situations involving child abuse, elder abuse or a plan to hurt yourself or others. These situations are rare but they do occur.

It is also important for you to know a few things about the clinic. We are a training center and in almost all cases, the counseling here is provided by Master's level interns. This does mean that we do not prescribe or provide any medication or have in house crisis services. Our intern staff does turn over once a year, in between the months of May and July. Please note that our treatment model at the clinic is that most clients will receive 12 sessions with their therapist, although certainly that can be extended if the circumstances warrant longer treatment.

We do offer a sliding scale for payment and we can accept Medicaid. We will need to verify that your Medicaid is active and that it is a form that we can accept—there are some forms of Medicaid (like out of state or out of our county area) that we can not accept. If you have Medicaid, please bring your card to the first appt. If you are using the sliding scale, please know that the first appointment is $35. Your clinician will set your ongoing rate at the time of the first appointment. The options are $30, $50, $70 and $90.

We don't want cost to be an added stressor, so please consider your monthly budget when choosing your sliding scale alternative, and plan on coming every week or every other week. It is also important to budget enough time for that first appointment (20-30 minutes for registration and 90 minutes for the actual appointment. Also, please remember that therapy itself will feel a bit different than the first contact which is a history gathering appointment.In addition, your therapist must review your situation with their supervisor before they can offer a next appointment time-- they will call you in a few days with an appointment. If we are not able to serve you, we will give you some appropriate referrals.

 

Where referred from? How did you hear about us?

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Type of Counseling Requested:




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Full Name

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Age:

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Date of Birth:

 

Occupation:

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Best phone number to reach you: 

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Is it OK to leave private voicemail on this number?


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Do you want to use an email for scheduling purposes?


 

If the above response is Yes, please include your email address here:

Medicaid

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Do you have medicaid?


 

What is the number on your card?

 

Which county and/or state is your Medicaid from? (our area is: Boulder, Broomfield, Clear Creek, Gilpin, Jefferson Counties) WE CAN NOT SEE MEDICARE, CO ACCESS, KAISER, ROCKY MOUNTAIN HEALTH PLANS EVEN IF THOSE THINGS ARE COMBINED WITH MEDICAID

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Are you a current Naropa student?  


 

If your response was Yes, which program are you in?

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Are you a Watson University student?


 

Have you been informed that Watson will cover 6 sessions for you? Your rate after the 6 sessions will be $20 per session.


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Are you currently married or have a partner living in the home?


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Any children living in the home?


These next questions are to determine if we are a good fit for your needs. Please be as open as you can.

 

Has there been any physical fighting in your home or relationships in the past two years? If yes, please explain:

 

Do you have drug or alcohol abuse issues currently or in the past?

 

Have you had any suicide attempts in the past two years? If yes, was there follow up treatment?

 

How are you coping with things? What do you usually do to cope when you are stressed?

 

Are you (or anyone to be seen at NCS) taking medications for depression, anxiety or other mental health issues?  (What medication, what dose?)

 

Have you (or anyone to be seen) ever been hospitalized for psychiatric reasons? If yes, for what? How long ago? How is that issue now?

 

Have you been in counseling before and was it a positive experience for you?

 

What's bringing you in for counseling at this time? (brief description)

 

How long has the problem been going on?

 

Has anything happened recently that made you decide to come in for counseling now?

 

Are there any other major stresses in your life or anything else we should know?