Name, Printed:
CONSENT TO TREAT
I, the undersigned, authorize Amy K. Bucciere, LCSW to administer mental health treatment as may be rendered
under general or specific instructions. I certify that no guarantees or assurances have been made to me as to the
results that may be obtained. Signature below verifies that I am in agreement with the course of treatment.
Signature: _____________________________________________
Witness: _____________________________________________
Amy K. Bucciere, LCSW
Date:
EXCEPTIONS TO CONFIDENTIALITY
1. Imminent threat to your own safety or the safety of others. Should imminent threat be reasonably determined,
therapist reserves the right to initiate mandated treatment.
2. Reasonable suspicion of danger to a child, elder and/or other protected parties. The situation will be reported to
the appropriate authorities for their further investigation.
3. Signed Release of Information. Therapist may request written permission to discuss aspects of your treatment
with various individuals like family members and physicians.
4. Please be aware that e-mail may not be confidential and may not be read in a timely fashion.
5. In the case of subpoena and other legally protected investigations, therapist will participate in to the extent
mandated. Therapist will not aid or abet the perpetration of crimes.
6. If your treatment is covered fully or in part by health insurance, be aware that coverage always requires a
diagnosis. I will be glad to discuss your diagnosis with you; please contact your insurance company for information
about their policies.
I understand the above exceptions to confidentiality as a condition of treatment.
Signature: _____________________________________________
Witness: _____________________________________________
Amy K. Bucciere, LCSW
Date:
Name, Printed:
CANCELLATION POLICY
Please initial each statement to indicate your awareness of the policy.
______ Appropriate payment (i.e. copay) is required at time of treatment (cash or check).
______ Cancellations within 24 hours of appointment will be charged a $50 fee.
______ Any change in insurance coverage or contact information must be provided at your next
appointment. Lapse in coverage may obligate you to out-of-pocket fee coverage.
CLINICAL RELEASE OF INFORMATION, EMERGENCY ONLY
Amy K. Bucciere, LCSW may request that a licensed and insured clinical practitioner contact you regarding
scheduling or similar issues should Amy be suddenly unavailable (by example, if therapist has a health emergency
and cannot contact you personally).
Your signature gives permission to RELEASE CONTACT, NOT CLINICAL, INFORMATION IN CASE OF
EMERGENCY ONLY.
Signature: _____________________________________________
Witness: _____________________________________________
Amy K. Bucciere, LCSW
Date:
LIMITS ON SCOPE OF SERVICES
I reserve the right to decline non-compulsory involvement in any patient’s legal or evaluative matter(s) that may
interfere with or go beyond my clinical obligation to my patients. This can include but is not limited to divorce
proceedings, custody hearings and disability claims for compensation. This does not include situations in which
therapist’s involvement is court-ordered.
Signature: _____________________________________________
Witness: _____________________________________________
Amy K. Bucciere, LCSW
Date:
Name, Printed:
RELEASE OF INFORMATION
I, ________________________, give permission to Amy K. Bucciere, LCSW, to exchange information with the
below individuals with the goal of improving assessment and treatment planning and coordinating treatment.
Therapist will share the least information possible for sufficient collaboration. This release is effective from the
date of signature through termination of treatment or by revocation of permission, whichever occurs first.
EMERGENCY CONTACT: REQUIRED
Name: ___________________________________________
Contact Information: _____________________________________________
Relationship: ___________________________________________
Name: ___________________________________________
Contact Information: _____________________________________________
Relationship: ___________________________________________
I consent to the gathering of collateral information with the above individuals to forward the course of my care. I
understand that I may revoke consent to any or all individuals at any time, verbally or in writing.
Signature: _____________________________________________
Witness: _____________________________________________
Amy K. Bucciere, LCSW, MSW
Date:
Beck Anxiety Inventory
Indicate how much you have been bothered by that symptom during the past month, including today.
Not At All
Mildly but it didn’t
bother me much.
Moderately - it
wasn’t pleasant at
times
Severely – it
bothered me a lot
Numbness or tingling
0
1
2
3
Feeling hot
0
1
2
3
Wobbliness in legs
0
1
2
3
Unable to relax
0
1
2
3
Fear of worst happening
0
1
2
3
Dizzy or lightheaded
0
1
2
3
Heart pounding/racing
0
1
2
3
Unsteady
0
1
2
3
Terrified or afraid
0
1
2
3
Nervous
0
1
2
3
Feeling of choking
0
1
2
3
Hands trembling
0
1
2
3
Shaky / unsteady
0
1
2
3
Fear of losing control
0
1
2
3
Difficulty in breathing
0
1
2
3
Fear of dying
0
1
2
3
Scared
0
1
2
3
Indigestion
0
1
2
3
Faint / lightheaded
0
1
2
3
Face flushed
0
1
2
3
Hot/cold sweats
0
1
2
3
Column Sum
The Beck Depression Inventory (21 questions)
1. Sadness
6. Punishment Feelings
0 I do not feel sad.
0 I don’t feel I am being punished.
1 I feel sad much of the time.
1 I feel I may be punished.
2 I am sad all of the time.
2 I expect to be punished.
3 I am so sad or unhappy that I can’t stand it.
3 I feel I am being punished.
2. Pessimism
7. Self-Dislike
0 I am not discouraged about my future.
0 I feel the same about myself as ever.
1 I feel more discouraged about my future than I
used to be.
1 I have lost confidence in myself.
2 I do not expect things to work out for me.
3 I feel my future is hopeless & will get only worse.
3. Past Failure
0 I do not feel like a failure.
1 I have failed more than I should have.
2 As I look back I see a lot of failures.
3 I feel I am a total failure as a person.
4. Loss of Pleasure
0 I get as much pleasure as I ever did from the
things I enjoy.
1 I don’t enjoy things as much as I used to.
2 I get very little pleasure from things I did enjoy.
3 I can’t get any pleasure from things I did enjoy.
5. Guilty Feelings
0 I don’t feel particularly guilty.
2 I am disappointed in myself.
3 I dislike myself.
8. Self-Criticisms
0 I don’t criticize or blame myself more than usual.
1 I am more critical of myself than I used to be.
2 I criticize myself for all of my faults.
3 I blame myself for everything bad that happens.
9. Suicidal Thoughts or Wishes
0 I don’t have any thoughts of killing myself.
1 I have thoughts of killing myself, but I would not
carry them out.
2 I would like to kill myself.
3 I would kill myself if I had the chance.
10. Crying
0 I don’t cry anymore than I used to.
1 I cry more than I used to.
1 I feel guilty over many things I have done or
should have done.
2 I cry over every little thing.
2 I feel quite guilty most of the time.
3 I feel like crying, but I can’t.
3 I feel guilty most of the time.
11. Agitation
16. Changes in Sleeping Patterns
0 I am no more restless or would up than usual.
0 I have not had any change in my sleeping pattern.
1 I feel more restless or would up than usual.
1 I sleep somewhat more/less than usual.
2 I am so restless or agitated, it’s hard to stay still.
2 I sleep a lot more/less than usual.
3 I am so restless that I have to keep moving or
doing something.
3 I sleep most of the day –or- I wake up 1-2 hours
early and can’t get back to sleep.
12. Loss of Interest
17. Irritability
0 I have not lost interest in other people or activities.
0 I am no more irritable than usual.
1 I am less interested in other people or things than
before.
1 I am more irritable than usual.
2 I am much more irritable than usual.
2 I have lost most of my interest in other people or
things.
3 I am irritable all the time.
3 It’s hard to get interested in anything.
18. Changes in Appetite
13. Indecisiveness
0 I have not experienced any change in my appetite.
0 I make decisions about as well as ever.
1 My appetite is somewhat greater/lesser than usual.
1 It’s more difficult to make decisions than usual.
2 My appetite is much greater/lesser than usual.
2 I have much greater difficulty in making decisions
than usual.
3 I crave food all the time or have no appetite at all.
3 I have trouble making any decision.
0 I can concentrate as well as ever.
14. Worthlessness
1 I can’t concentrate as well as usual.
0 I do not feel I am worthless.
2 It’s hard to keep my mind on anything for very
long.
1 I don’t consider myself as worthwhile and useful
as I used to.
19. Concentration Difficulty
3 I find I can’t concentrate on anything.
2 I feel more worthless as compared to other people.
20. Tiredness or Fatigue
3 I feel utterly worthless.
0 I am no more tired or fatigued than usual.
15. Loss of Energy
1 I get more tired or fatigued more easily than usual.
0 I have as much energy as ever.
2 I am too tired or fatigued to do a lot of the things
I used to do.
1 I have less energy than I used to have.
2 I don’t have enough energy to do very much.
3 I don’t have enough energy to do anything.
3 I am too tired or fatigued to do most of the things
I used to do.
21. Loss of Interest in Sex
0 I have not noticed any recent change in my interest in sex.
1 I am less interested in sex than I used to be.
2 I am much less interested in sex now.
3 I have lost interest in sex completely.
TOTAL SCORE: _________
PSYCHOLOGICAL AND MEDICAL HISTORY
Physicians you work with
Specialty
Date of last appointment
Practice Location
Please list all relevant medical and psychological issues and treatments, current or past, including trauma:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Allergies:
________________________________________________________________
Please list all current medications with dosage and length of time you’ve taken it:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
PSYCHOSOCIAL EVALUATION (Page 1 of 3)
Primary motivation for seeking therapy at this time:
____________________________________________________________________________
How long as this problem persisted? ____________________________________________
Under what conditions does the problem get:
Worse? ____________________________________________________________________
Better? ___________________________________________________________________
Who referred you here for help? ________________________________________________
What behaviors would you like to change? ________________________________________
Stressors
Briefly describe legal, financial, health, professional and/or other stressors:
__________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
Current Relationships/Family
Married
Domestic Partner
Single
Divorced
Widowed
Who lives in the home (please list age/gender of children or other residents in the home)?
________________________________________________________________________
________________________________________________________________________
Briefly describe the relationship(s) (ie, fun, conflictual, etc.)
________________________________________________________________________
Any psychiatric diagnoses, including substance abuse:
_________________________________________________________________________
Please describe your religion and its importance to you (ie, Jewish, somewhat active; very spiritual)
____________________________________________________________________________
List your support system:
____________________________________________________________________________
_____________________________________________________________________________
(Page 2 of 3)
Education and Employment
Highest level of education completed: ________________________________________
Current employment: ___________________________________________________
Family History
Mother/Mother Figure/Co-Primary Caregiver
Briefly describe your mother: __________________________________________________
____________________________________________________________________________
How did she discipline you? _____________________________________________________
How did she reward you? _______________________________________________________
How much time did she spend with you as a child (please circle)? [ Much ● Average ● Little ]
Mother’s occupation when you were a child: [at home ● worked part-time ● worked full-time]
As a child, how did you get along with you mother (please circle)? [ Poorly ● Average ● Well ]
How do you get along with your mother now (please circle)? [ Poorly ● Average ● Well ]
Is there anything unusual about your relationship with you mother? ________________________
_____________________________________________________________________________
Father/Father Figure/Co-Primary Caregiver
Briefly describe your father: __________________________________________________
____________________________________________________________________________
How did he discipline you? _____________________________________________________
How did he reward you? _______________________________________________________
How much time did he spend with you as a child (please circle)? [ Much ● Average ● Little ]
Father’s occupation when you were a child: [at home ● worked part-time ● worked full-time]
As a child, how did you get along with you father (please circle)? [ Poorly ● Average ● Well ]
How do you get along with your father now (please circle)?
[ Poorly ● Average ● Well ]
Is there anything unusual about your relationship with you father? _____________________________
_________________________________________________________________________________
(Page 3 of 3)
Siblings: I have _______ brothers and _______ sisters.
I was born # _________.
Significant Experiences
Describe significant experiences in childhood. This may include events like your or a loved one’s difficult illness, a
death, periods of frequent relocating, or anything else impactful on your growing up:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________