Ingrid Oliansky, Licensed Marriage and Family Therapist
MFC# 48975
Call for an appointment (818) 927-3855
Patient Information Form/Consent For Treatment
Name:
Address(Please include City, State and Zip Code):
Social Security Number:
Date of Birth:
Telephone
Home:
Cell:
Email:
Reason(s) for Requesting Psychotherapy:
Are you being Prescribed any medication for Mental Health?
If yes, Name of medication? Dosage?
Name of prescribing Physician:
Phone number of Physician:
Emergency Contact Name/Relationship and Phone:
LIMITS OF CONFIDENTIALITY
I am required by law to report incidences of and suspected incidences of child, elder and dependent adult abuse.
I am required by law to report if I believe you pose a danger to yourself or others (Suicide or Homicide)
If you sign a release for me to speak to a Physician or other medical professional.
If required by the HIPAA Privacy Act ( A copy will be furnished to you in our first session)
Initial here:
Please indicate if sessions are:
After Hours Emergency Access
I can be reached after hours by telephone at 818-927-3855. This number can also be texted. If you are unable to reach me, please leave a message and I will return your call as soon as I am able. If you are experiencing an emergency and cannot wait for a return call, please call 911.
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Consent For Treatment
I have been advised and understand that Behavioral Therapy is a treatment approach that has been widely validated by research. Further, the psychotherapeutic process may bring up uncomfortable physical sensations, feelings and reactions, including anxiety, sadness or anger, as well as positive feelings of wellness and general well being. I understand that this is a normal response to psychotherapy and that these reactions will also be the subject of our work together. I authorize Ingrid Oliansky, LMFT to carry out psychotherapy and diagnostic assessments during the course of my treatment and understand that any questions I have about my treatment will be explained to me in full upon my request. I also understand, that while treatment is designed to be helpful, Ingrid Oliansky, LMFT can make no guarantees about the outcome of my treatment. I agree to receiving emails or texts regarding our appointments.
Sign Here:
Date:
Is this address where you will be for our sessions?
If no, please provide address where you will be for sessions:
Cancellation/Missed Appointments Policy
Scheduled appointments are reserved especially for you. If an appointment is missed (No Show) or cancelled with less than 24 hours notice, you will be financially responsible for the FULL FEE (Not Co-Pay) set by your insurance carrier or the agreed upon fee if you are not utilizing insurance for our sessions. Your insurance company cannot be billed for missed sessions. Two consecutive no-shows or missed appointments will unfortunately result in termination of your therapy. If you wish to resume sessions after such termination, you are welcome to contact me to make arrangements.
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Selection is required.
Financial Agreement
If you are using insurance, you were provided your copay information (if any) with your appointment confirmation. Please note, these terms are dependent on your current insurance policy. They are subject to change if the terms of your policy change or if you change insurance companies. If you are paying privately, the fees were discussed on the telephone and confirmed in the Appointment Confirmation email. Please initial below to indicate that you are aware of and accept the financial terms.
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