Please read Part 1 of this form (INFORMATION FOR NEW CLIENTS) and acknowledge that you have done so by typing your name into the box labeled "Client's Signature" at the end of Part 1. (The form is SSL protected)

Tom Hansen, Ph.D., LCSW
P.O. Box 1582
Ellsworth, Maine 04605-1582
Phone: 207-664-0097
FAX : 207-664-2135
Email: info@hansencounseling.org
Web : www.hansencounseling.org

Part 1

INFORMATION FOR NEW CLIENTS

I provide you with the following information to help clarify the policies and procedures of my professional practice

DEGREES, CREDENTIALS & LICENSES:
Degrees:

  • M.S.W. Social Work, University of Connecticut, 1975
• Ph.D. Family Studies and Family Therapy, University of Maine 1989
Credentials:
• Clinical Externship, Structural Family Therapy, Philadelphia Child Guidance Clinic ’77-78
• Clinical Internship, Strategic Family Therapy, Augusta Mental Health Institute, ’83-84.
• Assistant Professor, Dept. of Human Development & Family Studies, U. of Maine, 1984 – 2001
• Assistant Professor, School of Social Work, U. of Maine, 1985 - 1991
License:
• ME Board of Social Work Licensure #LC1079 Licensed Clinical Social Worker

AREAS OF COMPETENCE:
• Consultation & psychotherapy for adolescents & adults in individual, couple, family and group modalities.


PROPOSED COURSE OF WORK: The course of my work usually involves 3 separate phases: 1) one to three interviews to identify problems, complete my assessment, & mutually develop a plan that includes goals & objectives; 2) the middle phase, which may include outside tasks or homework assignments designed to address the goals & objectives outlined in phase one; &, 3) an ending phase. At some point our work together will be finished, hopefully when your goals are met. Or perhaps you will just want to stop, or try a different therapist or type of intervention. In any case, I urge you to speak with me rather than just stop coming. Parting well is an important part of my work, and we should have a chance to say goodbye. I also want to learn from my clients what things I do that are helpful or not helpful. It is also helpful to think about your resources after the end of our work in an effort to strengthen what has been gained.

PROFESSIONAL ETHICAL STANDARDS: The ethical standards of my professional and my personal standards are strict about my responsibility to you. If at any time you question whether I have treated you properly, please tell me. If I do not satisfy you, you have a right to make a complaint to the authorities, and I will tell you how. Naturally, I hope that such a situation never occurs. You may contact the regulatory board from which I hold professional licensure at the following address: Department of Professional & Financial Regulation, 35 State House Station, Augusta, ME 04333 (207) 624-8603. Brochures containing rights and information under each of these regulatory bodies are also available in the waiting room.


Client Signature: *Required
By typing my name here I Acknowledge that I have read
INFORMATION FOR NEW CLIENTS


End - Part 1
 



After you have read INFORMATION FOR NEW CLIENTS (Part 1), please fill out the rest of the form (Part 2). When you have finished, type your signature into the textbox at the bottom of the form and click the "Submit" button to send your information to Dr. Hansen
 

Tom Hansen, Ph.D., LCSW
Counseling and Consultation
Relationships and Mental Health

Part 2

BASIC INFORMATION FORM

This information will provide background information about you or the person you are bringing & will help provide better services to you. Please provide the information requested as completely as possible. If you can’t answer a question or are unsure of how to answer, please skip the question. All information is confidential & cannot be discussed with anyone without your permission, within the limits of the law.

Date:

Full Name:   Date of Birth:
Social Security #:

Street Address:   City or Town:
State:   Zip:

Phone: Home:   Work:   Cell:

Email: Gender: M F

Insurance Name:   ID Number:
Date:

Group:   Plan:   Deductible:

Insured’s Name:   SS#:
Date of Birth:

Insured’s Place of Employment & Address:

Relationship Status: Single Married
Cohabitant Separated Divorced
Widowed   Never Married

Number of previous marriages:
Years in current/previous marriage:

Children’s names and ages:

Names/ages/relationships of people living in your household:

General Health: Present state of your health:

Chronic health problems:

Allergies:   Last physical exam:

Primary Care Physician:

Name, phone and relationship of person to contact if there is an emergency:

Who referred you to me?

What is the reason for your seeking my services?

How long have you had this concern?

How did the problem start?

Has this been a problem before?   If so, please explain:

Past/present use of drugs, including caffeine & tobacco:

Have you ever received counseling in the past?

If yes, when & with whom?

Employed?   Part-time  
Unemployed (how long)? Retired
 

Highest grade completed: Occupation:

Location of employment: Spouse/partner occupation:
 

This form is designed to help me gather information to evaluate your needs and develop a plan that fits you and your circumstances. If you have additional comments, questions or information you’d like to share about yourself, please do so below. Thank you.
 

Additional comments, questions or information:

 

Credit Card Information:

Credit Card Type: Visa MasterCard American Express

Credit Card Number:

Name on Card:

Expiration Date:




*Required
Signature of person completing form

End - Part 2