Michael Searby, LPC

Please fill out this entire form and send back to me prior to your first session.
*NOTE – I cannot meet with you until this form is filled out and signed.    
  
Name: ______________________________________________________________  
           (First)                           (MI)                               (Last)      

Nickname or preferred name: _____________________________________

Birth Date: ______ /______ /______ Age: ________

Sex: □ Male □ Female

Marital Status:   □ Never Married  □ Partnered  □ Married  □ Divorced  □ Widowed

Number of Children: __________      

Ages & Names of Children:_______________________________________

Local Address: ________________________________________________________________________________

Phone: (                          )    E-mail: __________________________

Referred by: _____________________________     

Are you currently receiving psychiatric services or professional counseling elsewhere?   □ Yes □ No  
If yes, Doctor or Professional’s name ____________________________          
Have you had previous psychotherapy?   □No   □Yes -  Previous therapist’s name__________________________   

Are you currently taking psychiatric medication?  □No   □Yes    If Yes, please list:
_________________________________________________

If no, have you previously taken psychiatric medication?   □No   □Yes   If Yes, please list:
___________________________________________

Have you ever been hospitalized for psychiatric purposes?   □No   □Yes   If yes, please explain:
______________________________________

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes,
Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046
etc.):  

________________________________________________________________________   

Are you having any problems with your sleep habits? □No  □Yes     If yes, check where applicable: □ Sleeping less □
Sleeping more □ Trouble falling asleep □ Trouble staying asleep

How many times per week do you exercise? __________      

Are you having any difficulty with appetite or eating habits? □No □Yes     If yes, check where applicable: □ Eating less □
Eating more □ Binge eating

How often do you use alcohol? __________________________

   
How often do you engage in recreational drug use? _____________________   

Have you had suicidal thoughts recently?   □ Frequently □ Sometimes □ Rarely □ Never      
Have you had suicidal thoughts in the past?   □ Frequently □ Sometimes □ Rarely □ Never      

Are you currently in a romantic relationship? □ No □ Yes  

If yes, how long have you been in this relationship? __________________  
If you are married, how long have you been married? ______________  
On a scale of 1-10, how would you rate the quality of your current relationship? _______      

In the past 2 years, please list any significant life changes or stressors:  
___________________________________________________________

Have you ever experienced:  

Extreme depressed mood yes/no  
Wild Mood Swings yes/no  
Rapid Speech yes/no  
Extreme Anxiety yes/no  
Panic Attacks yes/no  
Phobias yes/no  
Sleep Disturbances yes/no  
Hallucinations yes/no  
Unexplained losses of time yes/no  
Unexplained memory lapses yes/no  
Alcohol/Substance Abuse yes/no  
Frequent Body Complaints yes/no  
Eating Disorder yes/no  
Body Image Problems yes/no  
Repetitive Thoughts
(e.g., Obsessions) yes/no  
Repetitive Behaviors
(e.g., Frequent Checking, Hand-Washing) yes/no  
Homicidal Thoughts yes/no  
Suicide Attempt yes/no      

Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046
Are you currently employed? □ No □ Yes  
If yes, who is your current employer/position? __________________________________      
If yes, are you happy at your current position? __________________________________      
Please list work-related stressors, if any: ___________________________________      

Do you consider yourself to be religious? □ No □ Yes   If yes, what is your faith? __________________________  
If no, do you consider yourself to be spiritual? □ No □ Yes      

Have you ever been convicted of a felony?  □ No □ Yes -  If yes, Please explain _________________________________

Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following?
(circle any that apply and list family member, e.g., Sibling, Parent, Uncle, etc.):  
Depression yes/no  
Bipolar Disorder yes/no  
Anxiety Disorders yes/no  
Schizophrenia yes/no  
Alcohol/Substance Abuse yes/no  
Eating Disorders yes/no  
Learning Disabilities yes/no  
Suicide Attempts yes/no      

On a scale of 1-10, how would you rate your self-esteem currently? _______      

What do you consider to be your strengths? _________________________________________      

What are effective coping strategies you use? ________________________________________      

What are some areas you'd like to improve? __________________________________________

Please list 3 therapeutic goals:  

_______________________________________________________________________________________      

LIMITS OF CONFIDENTIALITY  

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a
client cannot be shared with another party without the written consent of the client or the client’s legal guardian.  
Noted exceptions are as follows:      

Duty to Warn and Protect  

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn
the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a
plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to
notify the family of the client.  

Abuse of Children and Vulnerable Adults 

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or
vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to
report this information to the appropriate social service and/or legal authorities.  
Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046
Prenatal Exposure to Controlled Substances 
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are
potentially harmful.  

Minors/Guardianship   Parents or legal guardians of non-emancipated minor clients have the right to access the clients’
records.      

I agree to the above limits of confidentiality and understand their meanings and ramifications.  

    CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that my health care provider wishes me to engage in a telehealth consultation.
2. My health care provider explained to me how the video conferencing technology that will be used to affect such
a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in
the same room as my provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the
convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and
technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if
it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard
to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have
been discussed with me in a language in which I understand.
6. Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
7. Though my provider and I may be in direct, virtual contact through telehealth, the telehealth service does not
provide any medical or healthcare services or advice including, but not limited to, emergency or urgent medical
services.
8. The telehealth service facilitates videoconferencing and is not responsible for the delivery of any healthcare,
medical advice or care.
9. I do not assume that my provider has access to any or all of the technical information in the telehealth service
10. To maintain confidentiality, I will not share my telehealth appointment information with anyone unauthorized to
attend the appointment.
By signing this form, I certify:
 That I have read or had this form read and/or had this form explained to me.
 That I fully understand its contents including the risks and benefits of the procedure(s).
 That I have been given ample opportunity to ask questions and that any questions have been answered to my
satisfaction.
BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS
DOCUMENT.

_________________________________________________________________   Client Signature

(Client’s Parent/Guardian if under 18)          

________________________________   Today’s Date          

Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046
CANCELLATION POLICY 

If you fail to cancel a scheduled appointment, I cannot use this time for another client in need and you will be billed for
the entire cost of your missed appointment. A full fee of $185 per clinical hour is charged for missed appointments or
no-show cancellations with less than a 48 hour notice, unless there is a significant emergency/medical issue. A bill will
be mailed directly to all clients who do not show up for or cancel an appointment and if the bill is not satisfied, the
matter will be turned over to a collection agency.  Payment for a scheduled session is to be paid prior to the start of the
session. Payment for therapy session is on a per session basis. There is no expectation of a commitment to continued
services.  

_________________________________________________________________       Client Signature

(Client’s Parent/Guardian if under 18)         

________________________________   Today’s Date

NOTICE OF PRIVACY PRACTICES

My practice is dedicated to maintaining the privacy of your personal health information as part of providing professional
care. I am required by law to keep your information private. How I use and disclose your protected health information is
with your consent (with the exception of The Limits of Confidentiality above).  I will use the information I collect about
you mainly to provide you with treatment, to arrange payment for services, and for some other business activities that
are called, in the law, health care operations. After you have read this notice I will ask you to sign a consent form to let
me use and share your information in these ways. If you do not consent and sign this form, I cannot treat you. If I want
to use or send, share, or release your information for other purposes, I will discuss this with you and ask you to sign an
authorization form to allow this.

There are some times when the laws require me to use or share your information. For example:

1. When there is a serious threat to your or another’s health and safety or to the public. I will only share information
with persons who are able to help prevent or reduce the threat.

2. When I am required to do so by lawsuits and other legal or court proceedings.

3. If a law enforcement official requires me to do so.

4. For workers’ compensation and similar benefit programs.

Your rights regarding your health information:

1. You can ask me to communicate with you in a particular way or at a certain place that is more private for you. For
example, you can ask me to call you at home, and not at work, to schedule or cancel an appointment. I will try my best
to do as you ask.

2. You can ask me to limit what I tell people involved in your care or the payment for your care, such as family members
and friends.

3. You have the right to look at the health information I have about you, such as your medical and billing records.
Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046
4. If you believe that the information in your records is incorrect or missing something important, you can ask me to
make additions to your records to correct the situation. You have to make this request in writing. You must also tell me
the reasons you want to make the changes.

5. You have the right to a copy of this notice.

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint
with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a
complaint will not change the health care I provide to you in any way. Also, you may have other rights that are granted
to you by the laws of our state, and these may be the same as or different from the rights described above. I will be
happy to discuss these situations with you now or as they arise.

7. If you wish to communicate electronically (for example through email, text, or Skype) the privacy of said information
cannot be guaranteed due to the nature of the medium.

This notice is effective as of the date of your receipt.

Michael L. Searby, LPC

Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046
Falls Church Wellness Center | 520 N Washington Street, Suite# 100 | Falls Church, VA 22046