Forms

Pilot Children’s Center
CA MFT#106589
California Region
831-262-1274

*Date

*Name

Name of Parent (if applicable)

Name of Spouse / Partner (if applicable)

*Birthdate of Client

*Birthdate of Insured

Home phone

*Cellphone

*Address

*Social Security Number (if required by insurance)

*Names and Ages of Family Members living with client

Primary Physician

Previous Therapists

Referred by

School currently attending (if applicable)

*Occupation

*Presenting Issues (1-2 sentences)

Family Preference - Play/Activity time Together

Parent Discipline Style / (If Applicable)

Background / Historical Information that may be useful for the Clinician to know

*Signature of Client or Signature of Parent/Guardian if applicable

Pilot Children’s Center
CA MFT#106589
California Region
831-262-1274

CLIENT CONFIDENTIALITY

The information discussed in therapy is confidential and cannot be disclosed to anyone. The exceptions to this rule are:

If there is evidence of child or elder abuse.

If the therapist learns that there exists a serious threat to the client or the safety of another.

If you sign a release of information as part of your insurance form or you are referred by an E.A.P. or managed care company that requests information.

If you sign a release of information for the therapist to share information with others specifically.

If there is a court order for the therapist to appear or produce records.

Cancellation Policy

For therapy to be effective, it is important to attend your appointments as scheduled. If you are unable to keep an appointment please notify the therapist. Out of respect for your clinician and other clients who are awaiting consultation slots, notification to cancel or reschedule a matching appointment must be provided at least 48 hours before the appointment start time. You will be responsible for the full hourly fee of your service.

Payment

Payment is due at the time of the appointment. We will automatically charge your credit card number you provide us once the session has concluded. Please note that we update our fees at the start of each year and as needed in line with growing business and team costs. Our fees listed below are subject to change with 30 days written notice.

Individual Session: $140

Couples Therapy: $160

Bio-Psycho-Social Assessment $250.00

I acknowledge receipt of this contract and agree to its terms.

*Date

*Client

Date

Parent

Pilot Children’s Center
CA License # 106589
California Region
831-262-1274

Release of Information

*Date

I,

, either for myself, Date of Birth

*, and/ or as the parent or guardian of

, Date of Birth

, release Caryn Torres and The Pilot Children’s Counseling Center to share information regarding myself or my child’s treatment with:

and / or

located at

The information may contain:

*This release will go into effect today,

and will end one year from today.

*Signed Client, and/or Parent or Guardian:

Pilot Children’s Center
CA MFT#106589
California Region
831-262-1274

Consent for Treatment

Date

I authorize The Pilot Counseling Center to treat myself or my child for mental health therapy services.

*Client Name or Parent/Guardian of Client:

*Client Name (if a minor):

*Signature of Client or Signature of Parent/Guardian if applicable: