forms

Michele Lane, LCSW, Board Certified Diplomate
6300 W. Loop South #215
Bellaire, TX 77401
713-668-3838

Name (Last, First, MI):



If using health insurance please fill out the following shaded section:

Insurance Company for Mental Health:
I no longer accept EAPs.

I accept Blue Cross Blue Shield of Texas, Value Options, and United Behavioral Health as long as the plan is not an EAP.

Blue Cross Blue Shield of Texas
Value Options
United Behavioral Health
Cigna PPO

Co-payment (if known)

Must you meet a deductible before being eligible for a co-pay only?
Yes
No

I authorize the release of medical information or other information necessary to process this claim.
Your initials indicate your consent and are your electronic signature:



Date of Birth:
Street Address:
City: State: zip:

Cell phone:
email:



Spouse or Partner (If applicable)
Name (Last, First, MI):
Date of Birth:


How did you find Michele Lane LCSW?
Provider directory
Doctor's referral
Google
Friend
Psychology Today
Web article on 7 best therapists

I understand that if I am to cancel an appointment, I must give Michele Lane at least 24 hours advanced notice. Otherwise I will be charged $60 for each session missed.
Your initials indicate your consent and are your electronic signature:



Optional (you may want to specify your doctor)
I authorize the release of medical and/or psychological information to the person specified below:


Your initials indicate your consent and are your electronic signature:


Why are you seeking help? (describe giving specific examples).



Check goals that apply:
decrease depression
decrease anxiety
improve relationship
decrease anger
increase confidence
decrease obsessing about unfaithful partner

Have you been in counseling? yes no
If so, when with whom?


Have you ever been hospitalized in a psychiatric hospital? yes no
When and where?



Have you ever been sexually abused? yes  no
If so, how old were you?
by whom?

The following questions pertain to your father.
age now if alive:

Has your biological father had a history of? (check all that apply)
alcoholism
drugs
physically abusing
sexual abuse
property destruction
depression
mood swings
being verbally abusive
psychiatric hospitalization

My father's greatest ability is:


My father's greatest weakness is:



The following questions pertain to your mother.
age now if alive:

Has your biological mother had a history of? (check all that apply)
alcoholism
drugs
physically abusing
sexual abuse
property destruction
depression
mood swings
being verbally abusive
psychiatric hospitalization

My mother's greatest ability is:


My mother's greatest weakness is:


Family and School
Number of brothers:
Number of sisters:
Family member you are closest to:
What jobs have you had since high school?


Names of schools you have attended (If applicable):
High School
Junior College
Technical School
Four Year College or University

Highest Degree
GED
High School
Tech School
BA or BS
Graduate

As a child before 18 years old, which of the following describes your experience?
fearful of dark
being judged by others
nightmares
physically abused
moody
tantrums
parents' screaming
father hit mom
mom hit dad

Happy with
self
family
friends
school
father
mother

How many intimate relationships that lasted more than 10 months other than your current one:


In how many relationships were you sexually abused?

In how many relationships were you physically abused?

Unhappy with
self
family
friends
school
father
mother


Angry at
friends
school
father
mother


School Achievement
poor
average
good
excellent


Poor focus in school
elementary
junior high
senior high


School experiences
athletic
expelled
suspended
arrested
lonely
shy
popular
expelled
teased

Current Symptoms:
(within the past 3 months) Indicate number (1, 2, 3, or 4)
1: (1-11 times per year)
2: (1-3 times per month)
3: (1-3 times per week)
4: (1-6 times per day)