Client Intake Form

Emergency Contact: I acknowledge that the services I receive from Allyson Blythe, LCSW are confidential. I also understand that should Allyson Blythe, LCSW assess that I present a risk to myself or others, or that there is a potential risk to me, Allyson Blythe, LCSW is under obligation to report such risks. In case of an emergency, I release Allyson Blythe, LCSW to contact:

1. Consent to Treatment:
I understand that treatment is a cooperative effort that involves open and honest communication between myself and my therapist. Because difficult feelings and issues may need to be experienced and addressed, I understand there are certain risks associated with psychotherapy that include, but are not limited to: worsening of mood, behavior, and/or functioning. I acknowledge that the benefits of treatment may not be immediately realized and understand that no guarantee or assurance is made as to the results that may be obtained. I hereby consent to treatment.

2. Fee-For-Service:
I understand that I am fully responsible for payment of services and products provided. Payment is due at the time of service. I understand that I am responsible for payment for all services, missed, or late-cancelled appointments.

3. Release of Information / Assignment of Insurance Benefits:
I understand that in the course of my treatment, it may be necessary for Allyson Blythe, LCSW to share my mental health information with other specialists, physicians, and/or health care agencies. Mental health information may also be shared with my insurance carrier should I decide to submit claims to my insurance company.

4. Emergency Contacts:
I acknowledge that the services I receive from Allyson Blythe, LCSW are confidential. I
also understand that should Allyson Blythe, LCSW assess that I present a risk to myself
or others, or that there is a potential risk to me, Allyson Blythe, LCSW is under obligation to report such risks. In case of an emergency, I release Allyson Blythe, LCSW to contact: