Kristin Staroba LICSW 1201 Connecticut Ave NW Suite 710 Washington DC

20036

INTAKE AND PRACTICE INFORMATION

Today’s date ______

Your name________________________________________Date of birth_______________

Mailing address_____________________________________________________________

__________________________________________________________________________

Email address ________________________________________Tel ___________________

Is it ok with you to receive emails and/or texts – whose confidentiality cannot be guaranteed --
regarding business such as scheduling? _____

SCHEDULING AND BILLING

Once we begin working on a regular schedule, I will charge for any scheduled session. If you need
to cancel an appointment, you may reschedule or make it up within the month. Please let me know
as early as possible when you must reschedule.
Please plan to pay for our initial session the same day. I bill monthly after that, and your payment
th
is due by the 15 . Payment for virtual sessions is via VENMO @kristin-staroba. If you prefer to
pay by check, I will give you an alternative mailing address (do not use the street address above).
You are responsible for submitting any insurance claims. My statement has all the needed info.

MEDICAL HISTORY
About when was your last general physical? __________________
How would you describe your physical health?_______________________________________
Are you being treated for any conditions or illnesses? _________________________________
Do you drink alcohol? _______ How much? ___________
Are you taking any medications? _________ What are they?____________________________

I acknowledge reading this form and agree to its terms:

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