Alain Montgomery, JD, Staff Attorney
The Therapist
July/August 2017

Introduction
There are certain professions where it is critical for the provider of services to obtain as much information as is reasonably appropriate at the start of the relationship with a prospective client or patient. Marriage and family therapists are an example of such a profession.

The patient intake process is mutually beneficial for both the therapist and the patient. For example, the patient intake process is the first opportunity you create for your patient(s) to identify—or to even reflect and contemplate on—the reasons they decided to embark on a therapeutic journey. Also, it provides you the opportunity to obtain information that may be relevant to the root cause or causes that underlie a patient’s presenting issue(s). For example, the responses provided within the patient intake can help you discern whether or not the patient’s issues are within your scope of practice and/or competence to treat, and if so, what modalities may be most helpful. Understanding a patient’s employment situation may indicate whether or not the patient qualifies for a sliding-fee. Even a vague, illusive, or non-responsive answer can be the starting point for a therapeutic dialogue and provide a window into what issues may arise in the future.

Hence, a comprehensive patient intake process, whether in writing, verbally, or both, can be the first collaborative step that the therapist and the patient take to facilitate the path to healing, wholeness, and well-being. This article, in addition to providing a sample Patient Intake Form, discusses some of the considerations to be mindful of with respect to information that is shared or communicated to the patient through the patient intake process.

Therapeutic and Clinical Considerations
In consulting with clinicians about some of the therapeutic and clinical considerations that could arise as part of the patient intake process, it was articulated that having a comprehensive intake questionnaire could potentially be off-putting or create an unduly burdensome experience for the patient. As one clinician poignantly observed, “Some of the information, especially personal information, which may be among the reasons for seeking therapy, may be too sensitive for the client to feel comfortable revealing on an intake form. A long comprehensive form in itself may be so off-putting, as to cause someone to not seek out therapy.” ¹ Another clinician recognized that a patient intake questionnaire should allow “...the client to be able to tell the story in his/her own terms.” And that, a lengthy and detailed form could “be emotionally difficult for [the patient] to fill out, especially if he/she has not even met the therapist.” ²

Hence, while it is important for a clinician to gather clinically relevant information, it is paramount that the therapist remain sensitive as to how the patient experiences the intake process. Therefore, it is within the discretion of the therapist to determine the appropriate balance between which questions to ask in the written intake questionnaire and which topics to broach at a later time as issues arise organically and as the bonds of rapport and trust between the therapist and the patient grow stronger. To ensure the patient feels comfortable at the initial stage of the interview or intake process, a questionnaire can reflect that certain information is “optional” so that the patient does not feel alienated or intimidated by some of the questions; or, pressured to provide information that he or she is not yet capable of, or willing to, reveal or share at the time.

Also, it is important to ensure that the patient is given an adequate amount of time and space either before or after the initial meeting to complete the intake questionnaire. For example, a patient may agree to take home a questionnaire and bring a completed (or partially completed) copy to a subsequent appointment. Alternatively, a clinician may have forms available on a website that can filled out before the first meeting.

Contacting a Patient’s Previous or Current Mental or Medical Health Care Providers
Sometimes to provide the best possible care, it may be necessary for a therapist to consult with a patient’s previous or current health care providers. Both state and federal law allow for permitted exceptions to confidentiality that permit licensed health care providers to exchange and discuss information about a patient without the patient’s written authorization as long as it is for the purpose or diagnosis of treatment.³

A patient may indicate during the patient intake process, or any time after, that he or she does or does not want you to contact a current or former provider. However, the law recognizes that clinicians may have a legitimate need to communicate with one another about the care of a mutual patient regardless of whether the patient consents. As explained above, the law provides exceptions to allow for these types of communications.

Avoiding Duplication of Services
During the patient intake, it may be valuable to inquire whether or not the patient is currently receiving therapeutic services from another psychotherapist and to ensure there is not a duplication of services. CAMFT Ethical Standard 3.10 states the following:

PATIENT SEEING TWO THERAPISTS: Marriage and family therapists do not generally provide professional services to a person receiving treatment or therapy from another psychotherapist, except by agreement with such other psychotherapist or after termination of the patient’s relationship with the other psychotherapist.

Thus, marriage and family therapists are encouraged to coordinate care with a patient’s other psychotherapist.

Third-Party Payers
It is legal and ethical for providers to accept payment from a third party. Payment by a third-party does not entitle the third party payer to a patient’s confidential information. However, as explained in the CAMFT Code of Ethics, marriage and family therapists, “represent facts regarding services rendered and payment for services fully and truthfully to third-party payers and others.”⁴ Hence, if a patient’s therapy is paid for by a third-party, the therapist may want to establish at the outset, if and when information regarding the patient’s treatment will be shared with a third-party payer. If the third-party payer is an insurance company with whom the therapist is contracted, the therapist may consider discussing how and when confidential patient information may be released to the insurance company.

Sliding Fee Scale
Under California licensing regulations, it is a form of unprofessional conduct to fail to disclose to the patient the fee to be charged for the professional services or the basis upon which the fee will be computed.⁵ This includes sliding fee schedules offered by a therapist to patients who face a variety of financial circumstances, such as, being on a fixed income, being unemployed, or having limited resources due to extenuating circumstances.

Scope of Competence
Understanding at the outset what a patient’s presenting issues are can help a provider discern whether or not the patients issue are within the provider’s scope of competence to treat based on the provider’s specializations or areas of expertise obtained through training, education and experience. Evaluating how your competencies may be able to serve or benefit the patient will help you determine whether or not a higher level of care of different type of care should be recommended.

Sample Patient Intake
The sample patient intake questionnaire/form incorporates a myriad of subject matters and areas. It is by no means intended or suggested that this sample serve as the model or template that you use for your patient intake form; or, that you adopt this sample to serve as your patient intake questionnaire.

The sample is meant to provide you with ideas about how to make your patient intake as inclusive, informative and insightful as possible given the client population you serve. Therefore, some sections, questions, and response categories may be more relevant and useful than others depending on the setting in which you work, your specializations, and your clientele.

Final Words
No matter how much information you gather about your patient during the intake process, the course of treatment is obviously not a forgone conclusion. The knowledge you have of your patient, and the information you gather from your patient, will expand as the bonds of trust between you and your patient grow over time. It is your decision as a practitioner to decide what questions will be the most useful in establishing trust and rapport at the outset of treatment. The patient intake process is a good place to start.

Clearly, there is no limit as to what you can include to be part of your patient intake. The intake can be insightful and provoking for both you and your patient. Evasive responses could be the reason for in-depth discussions. Very detailed responses may help you determine whether it is more appropriate to make a referral to a different type of provider or help you discern the modality that can be the most helpful for your patient.

So, how well do you know your patient?

---

Alain Montgomery, is a paralegal for CAMFT. Alain is available to answer member calls regarding ethical and licensure issues.

Acknowledgment: I’d like to thank Ronald Mah, LMFT and Jane Kingston, LMFT for offering such valuable insights and information and for making this article possible.

---

Endnotes
¹ Ronald Mah, LMFT
² Jane Kingston, LMFT
³ California Civil Code, Section 56.10(c) and 45 C.F.R. Section164.502
⁴ CAMFT Code of Ethics, Section 9.5.
⁵ California Business and Professions Code, Section 4982(n)

---

This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.