INTAKE /ASSESSMENT FORM

Welcome! These forms will give you the chance to describe your situation and history. Please fill them out as completely
as possible and have them ready before your first counseling session.

CLIENT INFORMATION

Name:

Date of Birth: Age: ________ ❒ Female ❒ Male ❒ Non-binary

Address:

Occupation: _________________________________ Employer: _________________________

School (if student):

Phone (h): Messages ok at home? ❒ Yes ❒ No

Phone (cell): Messages ok on cell? ❒ Yes ❒ No

(Note: I cannot guarantee the confidentiality of cell conversations.)

Phone (w): Messages ok at work? ❒ Yes ❒ No

Email: Emails ok? ❒ Yes ❒ No

(Note: I cannot guarantee the confidentiality of email.)

Website:
May I have your permission to look at your website? ❒ Yes ❒ No

How did you find out about my services? _______________________________________

If referred by a person, may I have your permission to thank him/her? ❒ Yes ❒ No

Religious Affiliation:

Ethnic/Cultural Heritage:

MARITAL STATUS

❒ Single ❒ Married (legally) ❒ Divorced Total # of marriages:__________________

❒ Cohabitating ❒ Divorce in process ❒ Separated ❒ Widowed Other:_________________

Assessment of current relationship (if applicable): ❒ Good ❒ Fair ❒Poor

FAMILY INFORMATION
Relationship Name Age Sex Type( bio, step, etc.) Living with
you?
Mother ______________________ ______ ______ ________________ ❒ Yes ❒ No
Father ______________________ ______ ______ ________________ ❒ Yes ❒ No
Spouse/SO ______________________ ______ ______ ________________ ❒ Yes ❒ No
Children/ ______________________ ______ ______ ________________ ❒ Yes ❒ No
 Intake/Assessment – p. 2

Siblings ______________________ ______ ______ _______________ ❒ Yes ❒ No

_____________________ _____ _____ _______________ ❒ Yes ❒ No
_____________________ _____ _____ _______________ ❒ Yes ❒ No
(Continue on back or extra page if needed

EDUCATION
Fill in all that apply Years of education: _______________ Currently enrolled: ❒ Yes ❒ No
__________High School grad/GED __________College
__________Vocational: __________Graduate School
Other training:__________________________________________________________________
Special circumstances:____________________________________________________________

MILITARY
Military experience? ❒ Yes ❒ No Combat experience? ❒ Yes ❒ No
Where: _____________________________ Branch: _____________________________
Type of discharge: ____________________ Length of service: _____________________
Rank at discharge: _____________________

PERSONAL STRENGTHS
What do you do well and what activities do you enjoy? ___________________________________
_____________________________________________________________________________
_____________________________________________________________________________

What personal qualities would others say you have? _____________________________________

_____________________________________________________________________________
_____________________________________________________________________________

Who are some of the influential and supportive people, activities (e.g. walking) or beliefs (e.g.
religion) in your life? (Please describe) ________________________________________________
______________________________________________________________________________
______________________________________________________________________________

COUNSELING/MEDICAL HISTORY
Have you previously seen a counselor? ❒ Yes ❒ No

Approximate Dates of Counseling: __________________________________________________

For what reason? ________________________________________________________________

What did you find most helpful in therapy? ___________________________________________

______________________________________________________________________________

What did you find least helpful in therapy? ___________________________________________

______________________________________________________________________________

Have you used psychiatric services? Yes No Was it helpful? Yes No

Please describe. _________________________________________________________________
______________________________________________________________________________

Have you taken medication for a mental health concern? Yes No

:
_
_
)

_
_
_
_
_
_
_
_

 Intake/Assessment – p. 3

Name of medication Dates Taken Helpful?(Y/N)

Do you have other medical concerns or previous hospitalizations? Please describe. _____________
______________________________________________________________________________
______________________________________________________________________________

LEGAL ISSUES
Please list any legal issues that are affecting you or your family at present, or have had a significant
effect upon you in the past.________________________________________________________
______________________________________________________________________________

CURRENT REASON FOR SEEKING COUNSELING

Briefly describe the problem for which you/your adolescent desire to have counseling? __________
______________________________________________________________________________
______________________________________________________________________________

What would you like to see happen as a result of counseling? ______________________________

______________________________________________________________________________
______________________________________________________________________________

What is most concerning right now? _________________________________________________

______________________________________________________________________________
______________________________________________________________________________

CURRENT FAMILY AND SIGNIFICANT RELATIONSHIP

Strengths/supports (relationships, support groups, etc.)

Stressors/problems

Recent change

Changes desire

FAMILY CONCERNS
Please check any family concerns that you are having
❒ Fighting ❒ Disagreeing about Relatives
❒ Feeling Distant ❒ Disagreeing about Friends
❒ Loss of fun ❒ Alcohol Use
❒ Lack of honesty ❒ Drug Use
❒ Physical fights ❒ Infidelity
❒ Education problems ❒ Other
❒ Money ❒ __________________________
s
d
­­­­­­­­­
S

 Intake/Assessment – p. 4

SUBSTANCE USE
Please check substances you use on a weekly/monthly (circle) basis:

Alcohol _______ x per week / month Meth _______ x per week / month
Marijuana _______ x per week / month Ecstasy _______ x per week / month
Cocaine _______ x per week / month Other _______ x per week / month
Heroine _______ x per week / month

Check all that apply:

______ I believe that my substance use may be a problem.
______ I believe that my partner’s substance use may be a problem.

INDIVIDUAL CONCERNS
Please check any personal concerns that you are having:
❒ Sadness ❒ Grief/loss
❒ Crying ❒ Work issues
❒ Irritability ❒ Spirituality issues
❒ Loss of pleasure ❒ Alcohol Use
❒ Sleep problems ❒ Another’s Alcohol Use
❒ Eating problems ❒ Drug Use
❒ Hopelessness ❒ Another’s Drug Use
❒ Guilt ❒ Hurting Self _______________________
❒ Mood swings ❒ Hurting others
❒ Fear ❒ Anger/Rage
❒ Nightmares ❒ Abuse (childhood)
❒ Flashbacks ❒ Abuse (adult)
❒ Obsessions ❒ Distractible
❒ Anxiety ❒ Hearing things
❒ Panic ❒ Seeing things
❒ Suicidal thoughts ❒ Loneliness
❒ Suicidal acts ❒ Other

Comments:

Is there anything else you would like to share:

______________________________________________________________________________
______________________________________________________________________________

I understand that by signing below, I am stating the above information is true.

_____________________________________________ __________________________
Client Signature Date

_____________________________________________ __________________________
Parent (or guardian) Signature Date
 CONFIDENTIALITY STATEMENT
Susan Lessley, MA, LMFT
Licensed Marriage and Family Therapist

Under the rules governing Marriage and Family Therapists in the state of Minnesota, a therapist,
and employees and professional associates of the therapist, must not disclose any private
information that the therapist, employee, or associate may have acquired in rendering services except
as follows.

• When the Board of Marriage and Family Therapy is reviewing a therapist. The Board shall
be allowed access to records of a client treated by a therapist under review if the client signs
a written consent permitting access. If no consent form has been signed, the hospital, clinic,
or licensee shall first delete data in the record that identifies the client before providing it to
the board.

• When disclosure is required by state law like prenatal exposure to drugs and alcohol, reports
of child abuse and neglect and vulnerable adults abuse and neglect.

• When failure to disclose the information presents a clear and present danger to the health or
safety of an individual.

• When the person, employee, or associate is a defendant in a civil, criminal, or disciplinary

action arising from the therapy.

• When the patient is a defendant in a criminal proceeding and the use of the privilege would
violate the defendant's right to a compulsory process or the right to present testimony and
witnesses in that person's behalf.

• When a patient agrees to a waiver of the privilege accorded by this section, and in
circumstances where more than one person in a family is receiving therapy, each such family
member agrees to the waiver. Absent a waiver from each family member, a marital and
family therapist cannot disclose information received by a family member.

• Communication via cellular telephone or electronic mail is not guaranteed to be confidential.

I understand this and discuss my personal information at my own risk.

All other private information must be disclosed only with the informed consent of the client.

My signature below means I have reviewed and understand the points above, as well as received a
copy of this form.

Client Signature ____________________________________ Date _______________________

Client Signature ____________________________________ Date _______________________

Susan Lessley, MA, Licensed Associate Marriage and Family Therapist

600 Twelve Oaks Center Drive #642E, Wayzata, MN 55391 612.581.7381 (1/21)
 MINNESOTA MENTAL HEALTH BILL OF RIGHTS
Susan Lessley, MA
Licensed Marriage and Family Therapist
600 Twelve Oaks Center Drive, Suite 642G
Wayzata, MN 55391
612.581.7381

Practitioner: Susan Lessley, M.A., LMFT

THE STATE OF MINNESOTA HAS NOT ADOPTED UNIFORM EDUCATIONAL

AND TRAINING STANDARDS FOR ALL MENTAL HEALTH PRACTITIONERS.
THIS STATEMENT OF CREDENTIALS IS FOR INFORMATION PURPOSES ONLY.

The Mental Health Bill of Rights provides that:

 You have the right to file a complaint in writing or through a phone call with the
practitioner’s supervisor. The supervisor is Steven McManus, LMFT, 763-442-4434, 7575
Golden Valley Road, Suite 305, Golden Valley, MN 55427.
 You may file a complaint with the Office of Mental Health Practice, 2829 University Avenue
SE, Suite 340, Minneapolis, MN 55414-3239. Their phone numbers are (612) 617-2105;
TTY: (800) 627-3529; and fax: (612) 617-2103.
 You, the client, are billed directly for services, or your insurance coverage may be billed with
your permission.
 You have a right to reasonable notice of changes in services or charges.
 You have the right to receive a summary, in plain language, of the theoretical approach used
by the practitioner in working with clients.
 You have the right to complete and current information concerning our assessment and
recommended course of treatment, including the expected duration of treatment.
 You have the right to expect courteous treatment and to be free from verbal, physical, or
sexual abuse by the Practitioner working with you;
 Your records and transactions with the Practitioner are confidential, unless release of these
records is authorized in writing by the client, or otherwise provided by law.
 You have the right to be allowed access to records and written information from records in
accordance with Minnesota statutes.
 You should know that other services may be available in the community. To find out about
such services, you may call First Call for Help at 651-291-0211.
 You have the right to choose freely among available practitioners, and to change
practitioners after services have begun, within the limits of health insurance, medical
assistance, or other health programs.
 You have a right to coordinated transfer when there is a change in the provider of services.
 You may refuse services or treatment, unless otherwise provided by law.
 You may assert these and other rights without retaliation.

Client Signature ____________________________________ Date _______________________

Susan Lessley, MA, Licensed Marriage and Family Therapist

5407 Excelsior Blvd. Suite B, St. Louis Park, MN 55416 612.581.7381 (3/08)
 COUNSELING FEES

Cash, Check, or Credit Card

50 Minute Session $150.00
30 Minute Session $75.00

Fees are effective January 1, 2022 and are adjusted periodically. The above fees apply
to new clients or clients returning after a four month (or more) absence.

By signing below you are agreeing to the above fee schedule and understand payment
(cash, check, or credit card) is due in full at the beginning of each counseling session.

Comments or notes about fees or fee arrangements:

Client: ____________________________________ Date: ___________________

Client: ____________________________________ Date: ___________________

Parent/guardian: ____________________________ Date: ___________________

Counselor: _________________________________ Date: ___________________

Susan Lessley, MA, Licensed Associate Marriage and Family Therapist

600 Twelve Oaks Center Drive #642E, Wayzata, MN 55391 612.581.7381
 Page 1 of 4

AGREEMENT FOR THERAPY SERVICES

Susan Lessley Counseling
600 Twelve Oaks Center Drive, Suite 642E
Wayzata, MN 55391
612.581.7381
Welcome to the therapeutic practice of Susan Lessley, MA, LMFT. This document contains important information about
my professional services and business policies. It also contains information about my policies and practices to protect the
privacy of your health information. Please read this document carefully and let me know if you have any questions or
concerns. By signing this document, you will be stating that you were provided with this information and it will represent
a binding agreement between us.

Psychotherapy Services: Psychotherapy varies depending on the therapist, the client and the client’s particular situation
and goals. There are many different methods which may be used to deal with a particular situation, goals, and objectives.
For the best outcome, each client must choose to invest energy in the process and work actively on relevant topics both
during and between sessions.

Psychotherapy can have benefits and risks. The risks may include experiencing uncomfortable feelings like sadness, guilt,
anger, anxiety or frustration when discussing aspects of life. Psychotherapy has been shown to have benefits that can
include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and
significant reductions in feelings of distress. However, there are no guarantees as to what each client will experience.

What to Expect: The first few sessions will involve an evaluation of your situation including needs, goals, and objectives
to work toward. Psychotherapy can involve a significant investment of time, energy, and money. It is important to select
a therapist with whom you are comfortable working. If at any time you have questions about therapy, please discuss them
with me as they arise. If you decide to discontinue therapy, I will provide referrals to other therapists or other appropriate
resources if requested.

Sessions: I schedule 50-minute sessions. If you would like longer sessions, the price will be pro-rated according to the
length of appointment we agree upon. If you arrive late for an appointment, the remaining time of our scheduled session
is available to you if you have called to state you will be late. If you have not called, I may not be available after 15
minutes from the scheduled start time. At times, it may be appropriate to meet more or less than once per week if that is
consistent with the agreed upon treatment plan.

If you need to cancel a scheduled therapy session, you must do so at least 24-hours in advance. If you do not cancel a
scheduled appointment with at least 24-hours notice, or if you fail to attend a scheduled session, you agree to pay the full
fee for that session, unless it is agreed upon that the absence was due to uncontrollable circumstances.

Professional Fees: Fees are listed on the Counseling Fees document. Package rates are available which can be found on
my website (www.SusanLessleyCounseling.com). In addition to regular sessions, it is policy to charge the therapy rate on
a pro-rated basis for other professional services required. Other services include report writing, telephone conversations
lasting longer than 15 minutes, attendance at meetings or consultations with other professionals which have been
authorized, preparation of records or treatment summaries, and time spent performing any other professional service.
Often, it is not helpful to participate in a legal process concerning any therapy that may have been given. Therefore, I will
decline if asked to participate in any legal or court hearings. If it becomes necessary to participate, the rate for my
preparation and participation in a court hearing or other legal proceeding will be $350 per hour. You will also be charged
this rate for travel time, waiting time and agree to pay any additional necessary fees (for example, parking fees). Pre-
payment of expected fees will be required one week (7 days) in advance of legal proceedings. You understand you will be
billed for any remaining amount.

Susan Lessley, MA, Licensed Marriage and Family Therapist

600 Twelve Oaks Center Drive #642G, Wayzata, MN 55391 612.581.7381 (11/17)

 Page 2 of 4

Billing and Payments: You will be expected to pay the full agreed upon fee at the time of each session unless other
arrangements have been made. Payments may be made by check, cash, or credit card via PayPal, Square, or IvyPay.
Payment schedules for other professional services will be agreed upon when/if they are requested. If a payment by check
does not clear due to insufficient funds or any other reason, you will be expected to reimburse Susan Lessley Counseling
in full for any related bank fees.

Insurance Reimbursement: To provide you with the most personal and confidential therapy services, I do not submit
billing to insurance organizations. Your insurance provider may pay for out-of-network therapy services, depending on
your plan. Alternatively, you may use your FSA or HSA to cover services. Please check your coverage carefully.

Contacting Me: Because I do not take calls during sessions, I may not be immediately available by telephone. A
confidential voicemail may be left at 612-581-7381. Every effort will be made to return calls within 24 hours, more
promptly if possible.

If you are in an emergency situation, you may either call your therapist and follow the instructions for emergencies, or
immediately call the Crisis Connection at (612) 379-6363, the St. Paul Ramsey Crisis Intervention Center at (651)
221-8922, your local emergency services at 911, or call or go to the nearest hospital emergency room, telling them of
your emergency. You understand that you are NOT to wait for me to return your call in an emergency situation.

Social Media Policy: I do not interact or accept “friend” requests via social media sites (Facebook, LinkedIn, etc)
because it has the potential to compromise privacy and complicate our therapeutic relationship.

Emails, cell phones, computers and faxes: Computer, email, text, and cell phone communications can be relatively easy
to access by unauthorized people and hence, can compromise the privacy and confidentiality of such communication.
Emails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct
access to all emails that go through them. Additionally, emails are not encrypted, and faxes can be sent erroneously to the
wrong address. Our computers are equipped with a firewall, a virus protection and a password, and we also back up all
confidential information from computers on to CDs on a regular basis. The CDs are stored securely. If you communicate
confidential or highly private information via email, text, or cell phone, I will assume you have made an informed
decision and will view it as your agreement to take the risk that such communication may be intercepted, and will honor
your desire to communicate on such matters via electronic means. You agree that electronic communications are part of
your medical record. You agree to not use electronic communication for emergencies. Due to computer or network
problems, electronic communications may not be deliverable or in a timely manner.

Professional Records: The laws and standards of the therapy profession require that treatment records are retained and
kept for a period of 7 years after the last point of contact.. You are entitled to examine and/or receive a copy of your
record if requested in writing, unless it is believed that seeing them information would be emotionally damaging, in which
case they will be sent to a mental health professional of your choice. Because these are professional records, they can be
misinterpreted and/or upsetting to people who are not mental health professionals. Susan Lessley Counseling reserves the
right to charge $.75 per page for the cost of copying and $25.00 for administration costs.

Confidentiality: In general, the law protects the privacy of all communication between a client and a mental health
provider. I may only release information about your treatment to others if you sign a written authorization form. You may
revoke any such authorizations at any time, which must be in writing. However, in the following situations, your
authorization is not required to release your personal information:

• Therapist’s duty to warn another in the case of potential suicide, homicide or threat of imminent, serious harm to
another individual.
• Therapist’s duty to report suspicion of abuse or neglect of children or vulnerable adults.
• Therapist’s duty to report prenatal exposure to cocaine, heroin, phencyclidine, methamphetamine, amphetamine or
their derivatives, THC, and excesses and habitual use of alcohol.
• Therapist’s duty to report the misconduct of mental health or health care professionals.
• Therapist’s duty to provide a spouse or parent of a deceased client access to their child or spouse’s records.

Susan Lessley, MA, Licensed Marriage and Family Therapist

600 Twelve Oaks Center Drive #642G, Wayzata, MN 55391 612.581.7381 (11/17)
 Page 3 of 4

• Therapist’s duty to provide parents of minor children access to their child’s records. Minor clients can request, in
writing, that particular information not be disclosed to parents. Such a request should be discussed with the
therapist.
• Therapist’s duty to release records if subpoenaed by the courts.
• Therapist’s obligations to contracts (e.g. to employer of client, to an insurance carrier or health plan.)

If an emergency happens to my therapist causing my therapist to be unable to provide services, my protected health
information may be shared with a colleague, Lynn Harris Luetgers, MA, LMFT, for both clinical and administrative
purposes, such as billing, scheduling, and quality assurance. She is bound by the same rules of confidentiality as your
therapist. By signing this document, I am agreeing with the release of my health information to Ms. Harris Luetgers if the
need arises.

While I am not an attorney, please discuss any questions or concerns you have about confidentiality with me at any time.
If you have specific legal questions about the laws regarding confidentiality, the exceptions, and how it may relate to your
situation, please seek formal legal advice from an attorney.

Other Client Rights: You agree that you understand the following:

• I have the right to request and receive confidential communication of my protected health information by alternate
means or at alternative locations. For example, clients may request the therapist send any correspondences to an
address other than the clients’ home address if not wanting family members to know about therapy.
• I have the right to request that the therapist change information in my record. I understand I am required to make
such requests in writing along with reasons for the requested changes. The client’s request will be noted.
• I understand I generally have the right to receive an accounting of any disclosures the therapist has made of
protected health information, which did not require client authorization.
• I understand my therapist may use or disclose my health information for treatment purposes including
presentation of my case in consultation with other professionals or consultants who are bound by the
legal framework of privacy and con dentiality for professional development and guidance purposes.
This case consultation may include case consultation with other therapists at Susan Lessley Counseling
or with therapists and supervisors outside of Susan Lessley Counseling. In most cases, outside
consultation will be undertaken without the use of any identifying information.
• I understand my therapist may use or disclose my health information for the purposes of payment and
health care operations including internal administration, participating in periodic le review, and normal
business accounting procedures

Changes in Services or Fees: Susan Lessley Counseling reserves the right to change the policies, practices, procedures
and fees described in this document. You will be notified within 30 days of any such changes.

Minors: If you are under 18 years of age, please be aware that the law may provide your parents with the right to
examine your treatment records. It is my policy to request an agreement from your parents that they consent to give up
access to your records. If they agree, I will provide them only with general information on how your treatment is
proceeding as well as a summary of your treatment when it is complete. However, if I feel that there is a high risk that you
will seriously harm yourself or another, I will notify them of my concern. Before giving your parents any information, I
will discuss the matter with you.

Safety: I strive to provide a safe environment for all. Please let me know immediately if you have concerns for your
safety while at my office. You agree that if you engage in verbal, written or physical behavior that is threatening to a
therapist or a therapist’s family, or any other person at Susan Lessley Counseling, any therapist at Susan Lessley
Counseling may identify you to the police, explain that you are a client at Susan Lessley Counseling, and report the
threatening behavior using your personally identifying information. Further, if needed, you agree that any therapist or
other at Susan Lessley Counseling may take other legal action to ensure safety for any therapist and any therapist’s family
or other people at Susan Lessley Counseling using your personally identifying information.

Susan Lessley, MA, Licensed Marriage and Family Therapist

600 Twelve Oaks Center Drive #642G, Wayzata, MN 55391 612.581.7381 (11/17)
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 Page 4 of 4

Information Received & Services Requested: The following materials pertaining to therapy (please check each) have
been reviewed. Copies of these materials are available on my website.

____ Confidentiality Statement ____ Fee Information

____ Privacy Information (HIPAA) ____ MN Bill of Rights

I understand the basic goals, ideas, and methods of this therapy. I have no important questions or concerns that the
therapist has not discussed with me. I understand that reaching the agreed upon therapy goal is not guaranteed. I
understand that therapy is successful for some people, moderately successful for others, and for some not successful at all.
I further understand that the initial symptoms or problems that were presented to the therapist may initially become more
intense.

I am agreeing to participate in the following types of services, while acknowledging that the course of therapy may
change, and the participants may change, by agreement of all parties.
_______ Individual Therapy
_______ Couples Therapy (partner name) __________________________________________
_______ Family Therapy (family names) __________________________________________
_______ Group Therapy

If I am participating in couple or family therapy I understand that:

• I do not have an individual file. Instead we share a couple or family file that holds all of the sessions regardless of
who participates in any particular session.
• All people participating in therapy need to consent for information to be released from a couple or family file.
• When I am a participant in couple or family therapy and come to a session without all of the other participants
listed above, I am giving my consent for my therapist to verbally share information from that session that the
therapist deems pertinent to our work together with the other people participating with me in therapy.

Conclusion and Signatures: By signing below I am indicating I have received and read the information in this document,
have discussed the contents with my therapist to my satisfaction, and agree to abide by its terms during the course of
therapy. I understand I may request a copy of this document.

______________________________ ______________________________ __________________

Client 1 - Print Name Signature Date

______________________________ ______________________________ __________________

Client 2 - Print Name Signature Date

Susan Lessley, LMFT ______________________________ __________________

Signature Date

Susan Lessley, MA, Licensed Marriage and Family Therapist

600 Twelve Oaks Center Drive #642G, Wayzata, MN 55391 612.581.7381 (11/17)