CARL GRODY, LISW-S
GRODY FAMILY COUNSELING

Note: information you provide here is protected as confidential information.

Client Name: __________________________________________________________________
Birth Date: ______ /______ /______
Address: ________________________________ City, Zip:_____________________________
Home Phone: __________________________May I leave a message? □Yes □No
Cell/Other Phone:_______________________ May I leave a VM? □Yes □No
E-mail/Texts: _________________________________ May I email/text you? □Yes □No
*Note: Email correspondence and texts are not guaranteed as a confidential method of communication. If you choose to use either or both, please limit information to details like scheduling. Check the boxes to allow communication via e-mail and/or text.
*Please initial here:______.
Referred by/how did you find me:________________________________________________
□ Single □ Cohabitating/Domestic Partnership □ Married □ Separated □ Divorced □ Widowed
Any children/ages:____________________________________________________________
Are you currently in a committed or romantic relationship? □ No □ Yes
If yes, for how long? __________________
On a scale of 1-10, how would you rate your relationship? __________
Describe any issues __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you previously received any type of mental health services (psychotherapy, psychiatric help, counseling, self help, etc.)?
□ No □ Yes, previous therapist/practitioner and time table: ______________________________________________________________________________________________________
Describe that process and if it was helpful: ______________________________________________________________________________________________________
______________________________________________________________________________________________________
Are you currently employed or in school? □ No □ Yes
Do you enjoy your work/school? Is there anything stressful about your current work/school? ____________________________________________________________________________________________________________________________________________________________________________________________________________
Rate your current physical health? (please circle)
Poor Unsatisfactory Satisfactory Good Very good
Please describe any health issues: ____________________________________________________________________________________________________________________________________________________________________________________________________________
Current sleeping habits (please circle)
Poor Unsatisfactory Satisfactory Good Very good
Please describe any sleep problems:
____________________________________________________________________________________________________________________________________________________________________________________________________________
Describe any difficulties you experience with your appetite or eating patterns:
____________________________________________________________________________________________________________________________________________________________________________________________________________
What hobbies, interests, or exercises do you participate in?:
____________________________________________________________________________________________________________________________________________________________________________________________________________
Do you experience anxiety, panic attack, obsessions, compulsions, fears, phobias?
□ No □ Yes If yes, when did you begin experiencing this?______________________________
Describe:___________________________________________________________________________________________________________________________________________________________________________________________________
Do you experience sadness, grief, depression? □ No □ Yes If yes, how long? ______________________
Describe____________________________________________________________________________________________________________________________________________________________________________________________________
Have you had or are you currently having thoughts of harming yourself? □ No □ Yes If yes, describe:___________________________________________________________________________________________________________________________________________________________________________________________________
Have you had any suicide attempts? □ No □ Yes: If yes, describe circumstances/dates: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you experience acute or chronic pain? □ No □ Yes; If yes, describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________
Do you take any medication? □ No □ Yes
Please list medication(s) & prescribing physician(s): ____________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been prescribed psychiatric medication? □ No □ Yes
Please list and provide dates and prescriber: ______________________________________________________________________________________________________
Have you ever felt you needed to cut down on your alcohol or drug use? □ No □ Yes
Have some people criticized your use or shared concerns about it? □ No □ Yes
Have you felt guilty, worried, or stressed about your drinking or drug use? □ No □ Yes
Describe any alcohol or drug related details or concerns: ____________________________________________________________________________________________________________________________________________________________________________________________________________
Describe any other types of addictive-type behaviors (internet, excessive gaming, gambling, sex, shopping, substances):
____________________________________________________________________________________________________________________________________________________________________________________________________________
What significant life changes or events have you experienced in the past year? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
In the section below, please identify if there is a family history of any of the following.
• If yes, please list and describe relative’s relationship to you as well as any effects of these issues on your relative(s) and on your relationship with the relative(s):
Alcohol/Substance Abuse y□ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Anxiety □ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Depression □ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Domestic Violence/Abuse y□ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Eating Disorders y□ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Schizophrenia □ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Suicide/ Attempts □ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Obsessive Compulsive Behavior/OCD □ No □ Yes ____________________________________________________________________________________________________________________________________________________________________________________________________________
Others? ____________________________________________________________________________________________________________________________________________________________________________________________________________
Have you been diagnosed or thought you had any of the issues listed above or others not listed? □ No □ Yes
If so, please describe: ____________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________
What is your highest level of formal education?______________________________________________________________________________________________________
Have you had or do you currently have any legal issues □ No □ Yes
If yes, describe:___________________________________________________________________________________________________________________________________________________________________________________________________
Do you consider yourself to be spiritual or religious? □ No □ Yes
If yes, please briefly describe your faith or belief:
____________________________________________________________________________________________________________________________________________________________________________________________________________
What do you consider your strengths or areas in your life that are going well?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What do you consider to be areas that need improvement? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What do you hope to accomplish in therapy? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Is there anything else I should know about your story, history, or situation?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OFFICE POLICIES/PRACTICES: Please review carefully.

TELEPHONE & EMERGENCY PROCEDURES: At times, phone contact is necessary between sessions. Clients are encouraged to keep phone contacts brief, if possible, and to address issues during your regularly therapy session. If you need to speak with me between sessions, please call (614) 477-5565. Your call will be returned as soon as possible. I am in solo private practice, so I won’t always be accessible in a crisis. If you or someone in your family is in a crisis that requires immediate attention and you can’t reach me, you agree to go to Netcare (if in Franklin County), go to a hospital emergency room, call 911 for assistance, or call the National Suicide Hotline at 800-784-2433.

CONFIDENTIALITY: All clients sign and agree to confidentiality/HIPAA guidelines indicating that I follow national standards as a Licensed Independent Social Worker to protect the privacy of your personal information. All information is kept private and confidential unless you provide written and specific authorization to share it. Exceptions to confidentiality include: threat of imminent and serious harm to self or others; abuse of a minor, elder or disabled adult; a court order; or in the event of a medical circumstance requiring immediate medical attention. In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information.

CONSULTATION: I may consult with licensed professionals regarding my clients when doing so might improve the outcome for the client; the client’s name or other identifying information is never disclosed. The client’s identity remains anonymous and confidentiality is fully maintained.

INSURANCE: I do not accept insurance.

FEES: $125/session. I accept cash, check, credit card, debit card, and cards attached to flexible health spending accounts. A sliding scale fee is available for qualifying clients. Please have payment ready at the start of sessions so as not to use your session time writing checks, etc.

SESSION LENGTH: Individual sessions are scheduled for one hour. Family and couple sessions are scheduled for 90 minutes.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, you agree that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. However, if my appearance at court on your behalf is required by law and you have signed a release form allowing this, my fee is $1,500 per day and must be paid in full 30 days prior to the expected court date. Note: I will NOT make a custody recommendation to the court in any circumstance. That falls outside the scope of my practice, and the possibility of making such a recommendation can be a negative influence during sessions. Any disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of me (Carl Grody, LISW-S) and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. The prevailing party in arbitration proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. The arbitrator will determine that sum.

ENDING THERAPY: If, at any point during therapy, I assess that I am not effective in helping you, I will discuss this with you. In such a case, I would give you a number of referrals that may be of help to you. If you request and authorize in writing, I will talk to the therapist of your choice in order to help. You have the right to end therapy at any time. If you choose to do so prior to the completion of the counseling process, I’ll offer to provide contact info of other qualified professionals whose services may better meet your needs. Once you have stopped attending sessions, you are no longer under my care, and our therapeutic relationship will be ended unless you reinitiate treatment with me. Length of counseling varies and is ultimately up to the client; however, please let me know if you feel ready to complete this course of counseling so that we can have one-to-two wrap-up sessions to solidify progress and so I can make recommendations to maintain progress.

SIGNATURE OF CLIENT: ____________________________________________________________________________________________________
DATE: ________________

SIGNATURE OF PARENT/GUARDIAN (IF CLIENT IS A MINOR): ____________________________________________________________________________________________________
DATE: ________________

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