Telephone: 603.886.3760 - Fax: 603.821.6142
154 Broad Street Nashua, New Hampshire 03063

Patient Intake Form

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We appreciate the opportunity to assist you and your trust in us to do so in a confidential and professional manner. The Emmaus Institute has served the greater Nashua community as an ecumenical and interfaith resource since 1984 in providing high quality, state of the art pastoral counseling, psychotherapy and psycho-educational services to individuals, couples, families and groups.

Enclosed you will find information about our Privacy Practices, Payment Policies and Procedures, Personal Inventory, Quick Inventory, Spirituality Index, Information form Patient Billing, and Medication Checklist. We ask that you complete these forms and bring them with you to your initial appointment.

In our initial appointment we review the counseling process and obtain your informed consent to proceed, we will review the Quick Inventory of Depressive Symptomatology (Self Report) and Issues and Personal Profile Statement. We will use these to establish base line goals for the process and to chart progress in resolving the issues we will be discussing and the solutions which you develop. We will ask you to present the concerns in more detail which have prompted you to utilize our resources.

Finally, in order to evaluate the effectiveness of our advertising please detail how you heard about the Emmaus Institute:

We look forward to assisting you.

“Were not our hearts burning within us as he talked to us on the road…?” Luke 24:32


Identification Data


Health Information


Religious Background


Personality Information


Marriage Information

If never married, omit this section.

List your children in birth order:

Child 1

Child 2

Child 3

Child 4


Answer this section describing your parents or parent substitute:

If parent(s) is/are still living, complete the following:

List your brothers and sisters in birth order:

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Sibling 5

Sibling 6


Agreement to Treat

This form will give you information about your treatment at Emmaus Institute. Pastoral counseling and psychotherapy are accepted approaches to treating mental health issues. In most cases persons so treated receive benefit from such treatment. There may be risks associated with this treatment. The results are not guaranteed and depend on a number of variables.

It is important that you are well informed about your rights and responsibilities in the treatment process. If you have any questions or need clarification about any part of this information, you should discuss it with your therapist. Your signature at the bottom of this form means that you understand and agree with all of the points listed.

Confidentiality, Ethics and Complaints
In general, the privacy of all communications between a patient and a licensed mental health counselor is protected by law, and we can only release information about our work to others with your written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent the Emmaus Institute from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, and judge may order our testimony is he/she determines that the issues demand it.

There are some situations in which we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a patient’s treatment. For example, if we believe that a child, elderly person, or disabled person is being abused, we must file a report with the appropriate agency.

If we believe that a patient is threatening serious bodily harm to another, we are required to take protective actions. These actions include, but are not limited to notifying the potential victim contacting the policy, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, we are obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. We will make reasonable efforts to fully discuss it with you before taking any action.

We may occasionally find it helpful to consult other professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our patients. The consultant is also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. We will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex. If you request, we will provide you with relevant portions or summaries of the state laws regarding these issues.

The Institute fee schedule is as follows: -
$150.- Evaluation/Psychiatric Diagnostic Interview
$130.- Couple/Family Psychotherapy
$120.- Individual Psychotherapy
$125 per hour - Report Preparation Fee

All telephone consultations will be billed at the agreed upon rate at a prorated basis. Fee payment is required at the end of each session. In the event that other arrangements are made with the Institute, a bill will be sent to you with payment due upon receipt of the bill.

If you have health insurance it should be understood that this is an agreement between you and your insurance company to pay you certain amounts for psychological care. Your doctor’s bill is an agreement between you and your doctor. You are responsible for the payment of our bill regardless of the status of your insurance claim.

All sessions are based on a forty-five /fifty (50) minute period per hour appointment.

A twenty-four (24) hour notice is required to cancel or reschedule sessions; otherwise
half payment will be required.

The Emmaus Institute has a 24 hour answering service. If you need immediate assistance the answering service will contact your clinician or another licensed clinician. In the event of an emergency, please call 911 or to your local hospital emergency room.

If you are taking any psychotropic medication, it is required by law, that you are see by a physician once a year for medical evaluation. Your clinician may find it useful to consult with your physician in regards to your medication intake.

The termination of treatment should be a mutual agreement between both client and clinician. The last session should summarize the progress you have made and bring closure to the therapeutic relationship.

Further, I authorize my therapist to contact my physician and/or psychiatrist if my therapist feels such consultation will be in my best interest.

I understand that pastoral counseling and psychotherapy are accepted approaches to treating mental health issues. In most cases person so treated receive benefit from such treatment. There may be risks associated with this treatment; the results are not guaranteed and depend on a number of variables.



Information for Patient Billing


Medication Checklist

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication 6

Medication 7

Medication 8


Summary Notice of Privacy Practices


Quick Inventory of Depressive Symptoms

Please select the one response to each item that best describes you for the past seven days.



Counseling Outcomes

What things will be different for you when your problem is solved?

What will others notice about you when your problem is solved?


Spiritual Index of Well-being

Which statement best describes your feelings and choices?