All Form Shortcodes

Sandra L. Kelly, LICSW
21 Paulding Drive, South Chatham, MA 02659
413-230-0508 • skellylicsw@gmail.com

Demographic Information

Name:

Intake Date:

Date of Birth:

Age:

Gender:

Preferred Pronoun:

Street Address:

City/State/Zip:

Primary Phone:

Okay to leave message? Text?

Phone Text

Cell:

Email:

Preferred Method of Contact:

Phone Text Email

Relationship Status:

Sexual Orientation:

Ethnic/Racial Identity:

Occupation:

Employer/School:

Spiritual Orientation:

Referred by:

Treatment Information

Please briefly indicate what you would like to address in therapy: [textarea treat_what class:line-multiline placeholder "" rows:3]

If you have other current healthcare or psychiatric providers, please indicate:

Primary Care Physician:

Phone:

Fax:

Address:

Last Physical Exam:

Psychiatrist:

Dates of Service:

Phone / Fax:

Medications (if any)

Medication	Dosage	Prescriber

Medical History

History of serious childhood illnesses:

Other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during your life time, please explain:

Have you experienced any head injuries?

Yes No

If yes, did you lose consciousness?

Y N

Have you experienced convulsions or seizures?

Yes No

Explain any allergies you have:

Substance Abuse History

Do you drink alcohol?

Yes No If yes, how frequently? and how many drinks

Have you ever blacked out from drinking?

Yes No If yes, number of times:

Have you ever needed medical attention due to use of substances?

Yes No If Yes please explain:

Do you use other illegal substances?

Yes No If yes, list substances & frequency:

Eating disorders Addendum

Ritualistic Behavior (Around food and Separate from food): please explain:

Behavior	Current Amount/Frequency	Past History — Max/Min (Date)
Binging
Vomiting
Restricting Calories
Laxatives
Diet Pills
Diuretics
Exercise
Caffeine use

Medical issues related to Eating Disorder: please check all that apply

Night Eating / Binge Eating Questions

1. Do you wake at least once during the night to eat?

Yes No

2. If you wake up in the night, do you find that it is necessary to eat something in order to fall back asleep again?

Yes No

3. Do you have little or no appetite in the morning and feel very hungry in the evening, often overeating between dinner and when you go to bed?

Yes No

Trauma, Miscellaneous, etc

Are you experiencing suicidal ideation?

Yes No

If yes, do you have intent or plans of harming yourself?

Are you experiencing homicidal ideation?

Yes No

If yes, do you have intent or plans of harming someone?

Have you experienced traumatic events in your life (physical, sexual, emotional abuse, witnessing traumatic events, death of friend or family member, car accidents, etc.)? If so, please provide a brief explanation:

Please indicate any other information that would be important or helpful to know about you:

Emergency Contact Information

Name:

Relationship:

Street Address:

City/State/Zip:

Primary Phone:

Ok to leave message?

Yes No

Secondary Phone:

Ok to leave message?

Yes No

Sandra L. Kelly, LICSW
South Chatham, MA 02659 • (413) 230-0508 • skellylicsw@gmail.com

Date:

Client Name:

DOB:

Address:

Psychotherapist-Client Services Agreement & Consent

The following information is given to provide a clear mutual understanding of the professional and business aspects of our relationship. Please read this information carefully, and feel free to ask questions or express any concerns you may have.

When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign or at any time in the future.

I. GENERAL INFORMATION

A. Psychological Services
Psychotherapy varies depending on the personalities of therapist and client, particular issues being addressed, length of treatment, and strategies used. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings and/or working with unpleasant life events. Psychotherapy often leads to significant reduction of distress, better relationships, and resolution of specific problems. Success in therapy requires hard work on your part, both during and between sessions.

B. Goals of Counseling
Counseling goals may be long-term (improving life quality, mindfulness, self-actualization) or immediate (reducing anxiety, depression, improving relationships, changing behavior, reducing substance use). You set your goals; I may offer suggestions on achieving them.

C. Intake and Assessment
During initial sessions we will:

Discuss your presenting concerns.
Get to know one another and determine treatment fit.
Review special circumstances affecting care.
Determine whether therapy together is appropriate.
Set appointment schedules.
Discuss additional evaluations if needed.
Secure necessary releases of information.

D. Confidentiality
Confidentiality is protected by law except in specific situations such as:

1. Judicial Proceedings

A judge may require testimony in certain legal cases.
Litigation where emotional state is introduced may require documentation.
Criminal cases may allow limited access to records.
Court-ordered evaluations & malpractice cases may require disclosure.

2. Harm to Self or Others

Mandatory reporting of abuse of children, elderly, or disabled persons.
Duty to warn if client threatens harm to others.
Required protective steps when client is suicidal.

3. Consultation and Supervision
Case consultation may occur; client identity is protected as much as possible.

4. Confidentiality and Technology
Online sessions (telehealth, email, text, phone) involve risks of unauthorized access. Clients are encouraged to safeguard communication devices.

E. Professional Records
Records are maintained for continuity of care and preserved for at least 7 years.

F. Client Rights
You have rights including:

Information about therapy.
Consultation with another professional.
Right to terminate therapy.
Anti-discrimination protections.

G. Payment and Professional Fees
Fees are due at time of service. Payment may be made by cash, check, Venmo, or credit card. Balances over 60 days incur finance charges. Collections may be used if needed.

H. Scheduling
Missed sessions without 48-hour notice will be billed. Insurance does not cover missed visits. Efforts will be made to reschedule, but availability cannot be guaranteed.

I. Insurance and Fees
I am out-of-network for several plans. With permission, I can assist with understanding coverage. Using insurance authorizes disclosure of clinical information when required by insurer. Session fee: $175 per 50 minutes.

J. Contacting Me
Calls are returned same day when possible. In emergencies, call 911 or visit the nearest emergency room.

Consent to Counseling and Privacy Practices

Your signature below indicates that you have read this entire Agreement, understand it, and agree to its terms. It also confirms receipt of privacy practices and HIPAA information.

Client Signature:

Date:

Printed Name:

Parent or Guardian Signature (if applicable):

Date:

Printed Name:

Sandra Kelly, LICSW

21 Paulding Dr. South Chatham, MA 02659
skellylicsw@gmail.com
NPI: 1073537877; Tax ID#: 11786

Good Faith Estimate

Public Health Service Act section 2799B-6, as added by section 112 of division BB of the CAA, requires providers, upon an individual’s scheduling of services, or upon request, to inquire if the individual is enrolled in a health plan or health insurance coverage, and to provide a notification of the good faith estimate (GFE) of the expected charges for furnishing the scheduled service with the expected billing and diagnostic codes for these items and services. If the individual is enrolled in a health plan or coverage (and is seeking to have a claim for the item or service submitted to the plan or coverage), the provider must provide this notification to the individual’s plan or coverage. In the case that the individual is not enrolled in a health plan or coverage or does not seek to have a claim for the item or service submitted to the plan or coverage, the provider must provide this notification to the individual. These provisions apply with respect to plan years (in the individual market, policy years) beginning on or after January 1, 2022.

Date

Patient Name

Date of Birth

Estimated Type of Services Provided

Estimated Frequency & Duration of Services Provided

Description of Treatment Modality(ies) Used

Treatment Goals

Estimated Charges for Each Service Provided

DISCLAIMER: These estimates may change as the treatment progresses and are not a guarantee of treatment frequency, length or cost. Your signature does not require you to receive psychotherapy services from me.

Provider Signature

Provider (Printed)

Patient Signature

Patient (Printed)

Sandra L Kelly, LICSW
South Chatham, MA 02659 • (413) 230-0508 • email: skellylicsw@gmail.com

Financial Agreement

Client Name:

Name of Insurance:

Insurance ID#

Group#

Subscriber Insurance, Subscriber DOB, Address (if different than subscriber):

Client DOB:

Client Address:

Client Phone:

I am an out of network provider for all insurance companies. If you would like me to provide you with an invoice (called a Superbill) so that you may be reimbursed through your insurance, please include the name of your insurance above. If you would like me to submit insurance claims on your behalf, please let me know. If you have a flex savings or Health Savings plan and would like to be reimbursed, I can supply you with a receipt.

If you are self-pay only (without insurance) no need to include your insurance information. It is helpful to be knowledgeable about your insurance benefits (deductible, copays, etc) as you may need to meet a high deductible before insurance pays for out-of-network mental health benefits. You can call the number on the back of your card for information.

Payment is due at time of appointment. I accept Venmo @Sandra-Kelly-33, credit cards, and Health or Flex Savings Credit & Debit Cards. If a check is preferred, please let me know.

Fees:

My fee is $175 per 50-minute session. I can offer a sliding scale if you’re unable to pay the full amount.

If you miss a session without canceling, or cancel with less than 48-hour notice, I will charge $175 to your credit card (cost of session) unless we both agree that you were unable to attend due to circumstances beyond your control. I will keep a copy of your credit card number in a secure location. Additionally, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

Credit Card #

Expiration date:

CV Code:

Credit Card Billing Zip Code:

Client printed name:

Client Signature:

Date:

413- 842-8500

413- 842-8500

Demographic Information

Treatment Information

Medications (if any)

Medical History

Substance Abuse History

Eating disorders Addendum

Night Eating / Binge Eating Questions

Trauma, Miscellaneous, etc

Emergency Contact Information

Psychotherapist-Client Services Agreement & Consent

I. GENERAL INFORMATION

Consent to Counseling and Privacy Practices

Sandra L. Kelly, LICSW

AUTHORIZATION FOR RELEASE/REQUEST OF CONFIDENTIAL INFORMATION

Sandra Kelly, LICSW

Good Faith Estimate

Financial Agreement

Fees: