What’s In The Intake?
Intake forms are a part of every service provider and health care worker’s paperwork. At Open Heart Holistic Therapy, you can complete the forms online or in-person, and we keep it short and sweet. Below is a short overview, but you can read it all at the link below.
Some basic part of a therapist’s intake are:
Basic Client Contact Information
Emergency Contact Information
Current Medications
Current Physical Issues
Current Emotional Issues
What you hope to achieve with therapy?
Along with that is some information that you read and sign:
Informed Consent (This is consenting for yourself or your child that you would like to receive EPT, and you understand I’m not a doctor, LMHC, and I cannot diagnose).
“We appreciate the opportunity to discuss your problems and concerns. We wish to make it clear that our intent is not to diagnose or prescribe, but to offer recommendations and information to help you establish a healthy order in your daily life. If you seek medical advice or treatment for a physical or mental health diagnosis, please consult a medical practitioner, licensed counselor, social worker, or qualified psychologist. If you are seeking ways to take responsibility for your own health, emotions, and overall well being, we are happy to be of assistance. I consent to receiving Emotional Polarity Technique™ at Open Heart Holistic Therapy LLC for myself and/or the identified client(s).”
Confidentiality Disclaimer
“At Open Heart Holistic Therapy LLC we strive to keep your sessions and information confidential. However, any online exchange of information via email, text, video, social media, or phone may not be secure. If a known breach occurs, we will let you know about it as soon as possible.”
Cancelation Policy (It’s our policy that a client must cancel 24 hour in advance or they forfeit the cost of the appointment. Of course, with COVID-19, there’s been a lot of flexibility and forgiveness necessary.)
“Payment is due at each session. If a client does not show up or cancels an appointment within 24 hours of the appointment, then they forfeit the time and cost of the appointment.”
COVID-19 In-Person Risks (This is simply acknowledging the risks meeting in-person during the pandemic, and understanding that.)
“I understand the risks of meeting in-person to receive EPT during the global pandemic of COVID-19. I will take precautions to minimize my exposure to COVID-19. I will not hold Open Heart Holistic Therapy LLC liable in case of exposure to COVID-19.”
Information Release Form (This is an optional form if you would like for me to be able to exchange information with another family member or health care provider.)
“If you would like for me to be able to speak to family members, friends, or healthcare providers about your care with EPT™ please provide a list of names, phone numbers, and emails with whom we can exchange information. If not, leave blank.”
ACE and Resiliency Score:
Resiliency Score. This is a 14 question test that correlates with resiliency in life. Resiliency is ultimately having a more positive/optimistic outlook on life, and also having plenty of people amongst your family and friends who you can count on to be there for you. Most people who are able to find me as their Holistic Emotional Support use Emotional Polarity Technique are fairly resilient. But whether your score is higher or lower, we’ll work through it in our sessions together—and it will get built up! If you want to learn more about this, check out my blog post on building resiliency.
ACE Score. ACE stands for Adverse Childhood Experiences and this is a 10 question test that correlates with physical health problems in adulthood. However, if you have a high resilience score, then it can mitigate some of these issues. When I see this score in EPT, I know there are things to work on. When someone has a very high ACE score, I emphasize to them the importance of paying attention to and caring for their emotional and spiritual health. It is tougher the higher the score, but there is hope. For even more information, check out my blog post on the ACE Score here.