Patient In-Take Forms

Please take your time when completing the intake forms and answer each section carefully and thoughtfully. The information you provide helps Dr. Smith better understand your history, concerns, and goals so your first session can be as productive and focused as possible.

Before submitting, review your responses to ensure everything is accurate and complete. Once you are finished, please click the Submit button only one time to ensure your information is properly received. Please note, If appointments are canceled less than 24 hour without a notice and it is not an emergency, you will be billed for the full session.

Patient’s First Name*

Patient’s Last Name*

Patient’s Date of Birth*

Patient’s Phone Number*

Patient’s Email*

Street Address*

City*

State*

Zipcode*

How did you hear about Dr. Smith? (Website, Referral, Google, Ads, Yelp etc.)

Insured’s Information

Health Insurance

Insurance Company*

Insurance Policy Number*

Insurance Owner’s First Name (Please use your Parent or Spouse’s name if not your own insurance)*

Insured’s Last Name (Please use your Parent or Spouse’s name if not your own insurance)*

Insured’s Date of Birth (Please use your Parent or Spouse’s information if not your own insurance)*

Insured’s Phone Number (Please use your Parent or Spouse’s information if not your own insurance.)*

Insured’s Email (Please use your Parent or Spouse’s info if not your own insurance)*

Street Address*

City*

State*

Zipcode*

Additional Patient Information

Relationship Status*

Duration of Relationship Status

Spouse/Partners Name (Parent’s Name for Minors)

List other people living in your home:

Physician Name:

List of Medications if any:

Anything else you’d like to discuss?

Background Information

Family/Significant Other

a. I live with:*

b. How many times have you been married?*

c. Important People in my life include:*

d. I was raised by:*

If other, please specify:

e. I remember my mother as:*

f. I remember my father as:*

PROBLEMS

a. My problems, as I see them, are the following:*

b. My problems, as others see them are the following (Please specify who):*

c. When I have a personal problem, I:*

EDUCATION

a. Positive experiences I had in school were:*

b. Problems I had in school were:*

EMPLOYMENT

a. Jobs I have had in the last 2 years:*

b. Problems I have had at work:*

LEISURE / SOCIAL

My leisure / social time is spent:*

STRENGTHS

My personality strengths / accomplishments are: (Please write at least three (3) points:)*

REQUIRED ASSISTANCE

I need direction / clarification and / or help with the following problems: (Please write at least three (3) points:)*

PLANS FOR THE FUTURE (WORK, INTERPERSONAL, SELF)

Please write at least three (3) points:*

Consent & Release

Consent & Release – By writing my full name and date, I hereby agree and understand that my therapist will release no information to others without my written consent unless there is clear and immediate danger to an individual or society, and then only to the appropriate private family members, professional workers or public authorities. I further authorize my insurance benefits to be paid directly to the Therapist and I understand that I am financially responsible for non-covered services. If appointments are canceled less than 24 hour without a notice and it is not an emergency, I understand that I will be billed for the full session.

Full Name:*

Signature Date:*

Health Insurance Portability and Accountability Act (HIPAA) Release

Health Insurance Portability and Accountability Act (HIPAA) Release

Professional Records – HIPAA requires that appropriate treatment records about Protected Health Information (PHI) be kept in two sets of professional records.
Clinical Record: Clinical Records include confidential information about reasons for seeking therapy, diagnoses, the goals set for treatment, progress toward these goals, medical and social history, treatment history, reports of any professional consultations, and your billing records.
Psychotherapy Notes: Psychotherapy notes may include the contents of conversations, analyses of those conversations and how they impact on therapy, all of which are not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record.
Communication with Insurance Companies and EAP counselors:
While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes unless you have given your signed, written Authorization for the Release/Exchange of Information. This release is limited to a specific person, organization, and/or period of time.

Clients Rights: The client may examine and/or receive a copy of the Psychotherapy Notes if requested in writing, unless the release of this information may cause you mental or emotional harm. As an alternative, the therapist may prepare an appropriate summary. It is recommended that records be reviewed in the therapist’s presence so that the contents can be discussed. Clients will be charged an appropriate fee for any preparation time which is required to comply with an information request.
In the event of the therapist’s death, all records will be transmitted to another professional and full confidentiality will be maintained. In the event of the client’s death, privilege to access your records passes from you to your estate.
By writing my full name and date, I hereby agree to the HIPPA policy statement.

Full Name:*

Signature Date:*

A Calm, Experienced Presence in Reno

Susan D. Smith PhD’s office, conveniently located in Reno, Nevada, offers a calm and private environment for therapy and psychological services. The space is designed to feel welcoming, professional, and confidential — providing a comfortable setting for individuals seeking counseling, cognitive behavioral therapy, and emotional support in the Reno area.

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