Please provide me with all of the background information that follows in advance of our first session. The more you tell me about yourself, the better I will be able to help you.
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Please Note:
You must be 18 or older.
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If you have a history of violence or are on anti-psychotic medication, I cannot work with you through e-mail or phone therapy. In-person therapy would be the best choice for you.
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IDENTIFYING INFORMATION: |
| Nameagemarital status |
address
City State Zip
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| phone |
any other identifying information that you wish to include.
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EMERGENCY CONTACT: The name, address, and phone number of someone I could contact in case of an emergency.
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| Nameagemarital status |
address
City State Zip
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| phone |
HEALTH: Any serious health problems you currently have or have had in the past which might influence our work together or my understanding of your personal life.
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ADDICTIONS: Degree to which you use alcohol or other drugs.
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VIOLENCE: Whether you are seriously considering either suicide or violence against another person.
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SUICIDE ATTEMPTS: Whether you have ever attempted suicide.
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THERAPY HISTORY: Whether you are now in therapy or ever have been in
therapy. (If you are in therapy now, your face-to-face therapist has a "veto power" over our relationship and you may share our e-mail with him or her to facilitate the decision.)
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OTHER NEEDED INFO: Any other information that I should have if I'm going to be able to help you.
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I usually respond within 48 hours. If you haven't heard from me in 48 hours, please re-send your letter.
(On weekends, please allow 72 hours...)
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PRINT THIS OUT, SIGN, AND RETURN THIS TO ME BY POSTAL MAIL along with your background information and first payment:
By signing below I agree to the following terms and conditions:
1) I have read the sections on confidentiality, privacy, and fees and agree to the terms specified in those sections.
2) I agree that when engaging in telephone or e-mail therapy, I am meeting with Susan Maroto in New Jersey and that we will abide by New Jersey laws regarding psychotherapy
3) The information that I have provided regarding my background and treatment history is truthful and complete.
Signature: __________________________________
Date:_____________
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Susan Maroto, LCSW
P.O. Box 404
Mt. Laurel, NJ 08054
United States
(856) 439-9293
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