The information in this form is kept confidential and will not be shared with any 3rd parties, unless the separate Authorization to Exchange Information form is filed.

E-Signature Agreement:

Each page of this form requires an e-signature. By entering your name in the e-signature field, you signify a legally binding signature and are agreeing that the information you provided is truthful and can be shared with Melinda Kincaid, Licensed Psychotherapist.

Name *

Birth Date *

Age *

Gender

Street Address *

Apartment, suite, etc

City

State

ZIP / Postal Code

Phone *

Email Address *

Marital Status *

E-Signature (type full name) *

The information in this form is kept confidential and will not be shared with any 3rd parties, unless the separate Authorization to Exchange Information form is filed.

E-Signature Agreement:

Each page of this form requires an e-signature. By entering your name in the e-signature field, you signify a legally binding signature and are agreeing that the information you provided is truthful and can be shared with Melinda Kincaid, Licensed Psychotherapist.

People Living With You

Name

Relationship to You

Age

Name

Relationship to You

Age

Name

Relationship to You

Age

Name

Relationship to You

Age

Name

Relationship to You

Age

E-Signature (type full name) *

The information in this form is kept confidential and will not be shared with any 3rd parties, unless the separate Authorization to Exchange Information form is filed.

E-Signature Agreement:

Each page of this form requires an e-signature. By entering your name in the e-signature field, you signify a legally binding signature and are agreeing that the information you provided is truthful and can be shared with Melinda Kincaid, Licensed Psychotherapist.

Occupation *

Employer *

How Many Years?

Partner's Occupation

Employer

How Many Years?

Primary Physician *

Date of last visit

Emergency Contact *

Phone *

Relationship *

Have You Had Counseling In the Past? *

When?

Was it a good experience? (describe)

Current Medications (name, dosage, duration)

Have you ever had psychiatric hospitalization? *

When?

Where?

Do you have any health problems or disabilities? *

Describe

Do you use alcohol or drugs, or have you in the past? *

Describe

Do you or any of your family members have a history of mental illness? *

Describe

Are you having suicidal thoughts or plans at this time? *

Have you had suicidal thoughts or plans in the past? *

Are you having thoughts of committing violence? *

Are you court ordered to attend counseling? *

What problems are you hoping to solve through counseling? *

The information in this form is kept confidential and will not be shared with any 3rd parties, unless the separate Authorization to Exchange Information form is filed.

E-Signature Agreement:

Each page of this form requires an e-signature. By entering your name in the e-signature field, you signify a legally binding signature and are agreeing that the information you provided is truthful and can be shared with Melinda Kincaid, Licensed Psychotherapist.

Sliding Scale Fee

Fee Agreement

*For groups of 3 or more, we charge a fixed rate of $275/hr

Total Income	Family of 1-2	Family of 3-4	Family of 5+
$15,000 and under	$105	$105	$105
$15,001 - $20,000	$115	$110	$110
$20,001 - $30,000	$120	$115	$115
$30,001 - $40,000	$125	$120	$120
$40,001 - $50,000	$150	$140	$130
$50,001 - $75,000	$175	$165	$160
$75,001 - $100,000	$200	$190	$185
$100,001 and above	$220	$210	$205

Total Income *

Household Size *

Your Fee (please reference chart) *

USD

Fee Agreement

I understand that fees for counseling are based on gross annual household income.
I understand and agree that payment is due when services are rendered unless an arrangement has been made in advance.
If I do not show or if I cancel an appointment without giving 24 hours notice, I agree to pay the full fee within 5 business days of the scheduled appointment.
If I have an unpaid balance when I terminate my counseling, I agree to make monthly payments until the amount is paid in full.
I agree to pay a $25 fee for any returned checks, payable immediately.

E-Signature (type full name) *

The information in this form is kept confidential and will not be shared with any 3rd parties, unless the separate Authorization to Exchange Information form is filed.

E-Signature Agreement:

Each page of this form requires an e-signature. By entering your name in the e-signature field, you signify a legally binding signature and are agreeing that the information you provided is truthful and can be shared with Melinda Kincaid, Licensed Psychotherapist.

CONFIDENTIALITY AGREEMENT

In California, Therapists are, by law mandated reporters of child abuse, dependent adult abuse and elder abuse. Therapists are, by California law, entitled to break confidentiality with clients for the following reasons:

The client is in danger of hurting themselves.
The client is in danger of hurting someone else.
The Therapist has reason to believe there is child abuse, elder abuse, or abuse of a physically or mentally dependent person occurring.

E-Signature (type full name) *

New Clients

Hello and welcome.