CITY____________________________________________STATE________ ZIP CODE_____________
DATE OF BIRTH:______________________________
AGE: ______________
HOME PHONE:__________________________
CHILDS CELL:________________ (ok to use?__) CHILDS EMAIL_________________________(ok to use?__)
PARENTS CELL________________________PARENTS EMAIL_________________________(ok to use?__)
Work phone: _______________________________ (ok to use?__)
Where did you hear about this Therapist?____________________________
Name of Physician__________________________________________ Phone:__________________
Clinic and Address: __________________________________________________________________
Medications prescribed/ reason for:________________________________________________________
Major Medical conditions/past/present:_____________________________________________________
Primary Health insurance company_______________________________________________
Name of Insured______________________________________________________
Address of Insured if different from Child’s address___________________________
Relationship to insured?______________________ Birth date of insured:_________
Insured Place of Employment____________________________________________
Insurance ID #:_____________________________ Group #_________________________________
Any other insurance held?
If yes, please complete information below:
Secondary Health insurance company_______________________________________________________
Name of Insured_____________________________ Birth date of insured________________
Insured Place of Employment_______________________________________________________
Policy Number________________________ Group Number______________________________
Please list an emergency contact: Name: ______________________________________________
Relationship:___________________ Phone:__________________________
Please sign and date below to give consent to contact this person in the case of an emergency. This only gives consent for
emergency contact. All other contact with this person needs to be expressed and specifically consented to in other signed
Sign Name:__________________________________________________ Date:_____________________
Please note: The Minnesota code of Agency Rules states that information may be disclosed to the family of a client, a potential
victim, public authorities or appropriate professionals when that disclosure is necessary to protect against serious harm being
inflicted on the client or another person.
I fully understand that my insurance coverage is a contract between my insurance company and myself
and it is my responsibility to know my benefits. Your therapist will usually verify benefits as a courtesy,
but it is not responsible for discrepancies between the information given and the actual coverage.
I hereby authorize and request payment directly to NANCY E. WILSON, M.S., L.P., under the terms of
my insurance policy and authorize the release of information needed to process claims.
I understand that I am financially responsible for treatment charges not covered by my insurance benefits.
Treatment co-pays are due at the time of the session. Any other arrangements must be discussed with your
In the event of a default on payment, I will pay in addition to the amount due, collection costs and attorney
fees as well as any service charges.
I have read and understand the above policy and agree to its content.
Signature of Parent___________________________________________Date________________
Nancy E. Wilson, M.S., Psychologist
14501 Granada Drive Suite 101
Apple Valley, MN 55124
Office Phone: 952-250-9952 FAX: 952-431-6448
Schedule times by calling 952-250-9952. The appointment time is reserved especially for you and we
require at least 24 hour cancellation notice. If you do not cancel 24 hours in advance you may be charged
for the time. If you miss an appointment, or cancel too late, you will be billed directly for the missed
session as these charges cannot be submitted to insurance companies. I schedule all appointments in
advance, and offer various times throughout the week. The “clinical hour” is 50 minutes in duration (less
if you arrive late).
Telephone Messages
You may reach me by calling my office number at (952)250-9952. I work part time out of my clinical office
and keep other office hours at home. If you do not reach immediately you may leave a message in my
confidential voice mail. I check this several times a day and will return your call during my next available
opportunity. My voice mail is not checked overnight, however, or during times that would be specified on
my voice message. In the case of an emergency, there are several emergency services available in the
Twin Cities. You can also call 911.
If this is a life or death issue, dial 911 or go to the hospital emergency room for evaluation. Do not leave
a voice mail message for this type of message, especially if it is overnight. Below I have listed local services
that provide 24 hours a day crisis lines:
Dakota County
Hennepin County
Crisis Connection
(952) 891-7171
(612) 374-3161
(612) 379-6363
(for all counties)
The fee for services is $100 an hour for counseling, and $160 an hour for Initial Intake appointments. If
I am an in-network provider for your insurance, then I am contracted by them and I will submit all
insurance forms necessary. I will also contact them to clarify your insurance coverage after our initial
appointment is scheduled. All co-pays are required to be paid at the time of the appointment. Testing or
consultation is made by arrangement.
If you have a private insurance that I am not contracted with you might still be eligible for insurance
reimbursement. While I will assist you in obtaining reimbursement, the ultimate responsibility for your bill
is yours. I encourage you to obtain as much information as you can about the mental health benefits that
your health insurance company provides for you.
Ending Therapy
Most often, we plan for ending therapy work during the last few sessions. If for some reason we have not
done that and you decide to stop, please let me know. I believe it is helpful to be clear with each other
about ending.
Client fill this out on his or herself:
Name: ________________________________________________Date:___________________
Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other
concerns or issues.” You may add a note or details in the space next to the concerns checked. Please circle
specific problems if all of them in the line do not apply to you.
Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals
Aggression, violence
Alcohol use
Anger, hostility, arguing, irritability
Anxiety, nervousness
Attention, concentration, distractibility
Career concerns, goals, and choices
Childhood issues (your own childhood)
Custody of children
Decision making, indecision, mixed feelings, putting off decisions
Delusions (false ideas)
Depression, low mood, sadness, crying
Divorce, separation
Drug use—prescription medications, over-the-counter medications, street drugs
Eating problems—overeating, undereating, appetite, vomiting
Fatigue, tiredness, low energy
Fears, phobias
Financial or money troubles, debt, impulsive spending, low income
Grieving, mourning, deaths, losses, divorce
Headaches, other kinds of pains
Health, illness, medical concerns, physical problems
Housework/chores—quality, schedules, sharing duties
Inferiority feelings
Interpersonal conflicts
Impulsiveness, loss of control, outbursts
(cont.)Adult Checklist of Concerns (p. 2 of 2)
❑ Judgment problems, risk taking
❑ Legal matters, charges, suits
❑ Loneliness
❑ Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations,
❑ Memory problems
❑ Menstrual problems, PMS, menopause
❑ Mood swings
❑ Motivation, laziness
❑ Nervousness, tension
❑ Obsessions, compulsions (thoughts or actions that repeat themselves)
❑ Oversensitivity to rejection
❑ Panic or anxiety attacks
❑ Parenting, child management, single parenthood
❑ Perfectionism
❑ Pessimism
❑ Procrastination, work inhibitions, laziness
❑ Relationship problems (with friends, with relatives, or at work)
❑ School problems (see also “Career concerns”)
❑ Self-centeredness
❑ Self-esteem
❑ Self-neglect, poor self-care
❑ Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”)
❑ Shyness, oversensitivity to criticism
❑ Sleep problems—too much, too little, insomnia, nightmares
❑ Smoking and tobacco use
❑ Spiritual, religious, moral, ethical issues
❑ Stress, relaxation, stress management, stress disorders, tension
❑ Suspiciousness
❑ Suicidal thoughts
❑ Temper problems, self-control, low frustration tolerance
❑ Thought disorganization and confusion
❑ Threats, violence
❑ Weight and diet issues
❑ Withdrawal, isolating
❑ Work problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambition
Any other concerns or issues:
Please look back over the concerns you have checked off and choose the one that you most want help
with. It is: ________________________________________________________________________
Please fill this out with basic significant information. We will discuss these things in our first session. Continue on back if you
need to. Omit any items you do not know or are uncomfortable writing about.
Adult fill this out on Child Client:
Name of Adult filling out form:____________________________________________________
Name of Client:_________________________________________Date:________________________
D.O.B. ____________________Age__________
Grade and School attended:__________________________________________________________
Do you have a job?:__________________________________________________________
Medications used/ reason for:_____________________________________________________
Significant illnesses in immediate family______________________________________________
Sisters and Brothers (list by birth order)
1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
4.. History of therapy (Therapist, title, length, dates, type of therapy). Did you find it useful?
5. History of childhood, adolescence, father, mother, siblings, family. Also, any significant school/learning issues.
6. Describe what you want your child to get out of therapy.
Consent to Treatment
I do hereby seek and consent to take part in the treatment by Nancy E. Wilson, M.S.,L.P.. I understand
that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the
treatment goals are in my best interest. I agree to play an active role in this process.
I understand that no promises have been made to me as to the results of treatment or of any procedures
provided by this therapist.
I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be
responsible for is paying for the services I have already received. I understand that I may lose other
services or may have to deal with other problems if I stop treatment. (For example, if my treatment has
been court-ordered, I will have to answer to the court.)
I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I
do not cancel and do not show up, I will be charged for that appointment.
I am aware that an agent of my insurance company or other third-party payer may be given information
about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that
if payment for the services I receive here is not made, the therapist may stop my treatment.
My signature below shows that I understand and agree with all of these statements.
Signature of client (or person acting for client) ____________________________________Date_______________
Printed name ______________________________________________
Relationship to client (if necessary)_____________________________________
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by
Child Checklist of Characteristics
Name of client_____________________________: Date:_____________Age: ________
Person completing this form:___________________________________________________
Feel free to add any others at the end under “Any other characteristics.”
❑Argues, “talks back,” smart-alecky, defiant
❑Bullies/intimidates, teases, inflicts pain on others, is bossy to others, picks on, provokes
❑Cruel to animals
❑Concern for others
❑Conflicts with parents over persistent rule breaking, money, chores, homework, grades,
choices in music/clothes/hair/friends
❑Cries easily, feelings are easily hurt
❑Dawdles, procrastinates, wastes time
❑Difficulties with parent’s paramour/new marriage/new family
❑Dependent, immature
❑Developmental delays
❑Disrupts family activities
❑Disobedient, uncooperative, refuses, noncompliant, doesn’t follow rules
❑Distractible, inattentive, poor concentration, daydreams, slow to respond
❑Dropping out of school
❑Drug or alcohol use
❑Eating—poor manners, refuses, appetite increase or decrease, odd combinations, overeats
❑Exercise problems
❑Extracurricular activities interfere with academics
❑Failure in school
❑Fighting, hitting, violent, aggressive, hostile, threatens, destructive
❑Fire setting
❑Friendly, outgoing, social
❑Hypochondriac, always complains of feeling sick
❑Immature, “clowns around,” has only younger playmates
❑Imaginary playmates, fantasy
❑Interrupts, talks out, yells
❑Lacks organization, unprepared
❑Lacks respect for authority, insults, dares, provokes, manipulates
❑Learning disability
❑Legal difficulties—truancy, loitering, panhandling, drinking, vandalism, stealing, fighting, drug
❑Likes to be alone, withdraws, isolates
Child Checklist of Characteristics (p. 2 of 2)
❑Low frustration tolerance, irritability
❑Mental retardation
❑Mute, refuses to speak
❑Nail biting
❑Need for high degree of supervision at home over play/chores/schedule
❑Overactive, restless, hyperactive, overactive, out-of-seat behaviors, restlessness, fidgety,
❑Oppositional, resists, refuses, does not comply, negativism
❑Prejudiced, bigoted, insulting, name calling, intolerant
❑Recent move, new school, loss of friends
❑Relationships with brothers/sisters or friends/peers are poor—competition, fights,
teasing/provoking, assaults
❑Rocking or other repetitive movements
❑Runs away
❑Sad, unhappy
❑Self-harming behaviors—biting or hitting self, head banging, scratching self
❑Speech difficulties
❑Sexual—sexual preoccupation, public masturbation, inappropriate sexual behaviors
❑Shy, timid
❑Suicide talk or attempt
❑Swearing, blasphemes, bathroom language, foul language
❑Temper tantrums, rages
❑Thumb sucking, finger sucking, hair chewing
❑Tics—involuntary rapid movements, noises, or word productions
❑Teased, picked on, victimized, bullied
❑Truant, school avoiding
❑Underactive, slow-moving or slow-responding, lethargic
❑Uncoordinated, accident-prone
❑Wetting or soiling the bed or clothes
❑Work problems, employment, workaholism/overworking, can’t keep a job
Any other characteristics:
Please look back over the concerns you have checked off and choose the one that you most
want your child to be helped with. Which is it?________________________________
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly
prohibited by law.