Client Information Packet

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1 Phone: Office locations: Highlands Ranch Medical Plaza II: 9331 South Colorado Blvd., Suite 60 Website: Highlands Ranch, CO Meridian Business Park near I-25 and Lincoln Ave: 9540 South Maroon Circle, Suite 250 Englewood, CO Client Information Packet Welcome I am privileged to have the opportunity to work with you with the hope of being helpful as your counselor. This packet contains Information and forms that I will need to have on file before I begin offering services to you. Please print, review, and complete the documents included in this Client Information Packet. The guidelines and instructions below will assist you: Guidelines Client Information Form - to be completed by client(s). If marriage/couple counseling, please have each individual complete a copy of this form. (Pages 2 & 3) Disclosure, Policy, and Fee Agreement - to be reviewed and signed by client(s) (Signature - Page 7) Once you have completed, reviewed, and signed all relevant documents please return originals to my office at your first appointment. I encourage you to retain a copy of this information for your records. Page 1 of 7

2 Client Information Form Personal Information Today s Date: Full Name: Street Address: City: State: Zip: Cell: Home phone: Work phone: Birthdate: In case of emergency, who should we notify? Name: Phone: Who referred you to us? Who is responsible for payment? Name: Relationship to patient: Marital Status (check one): Single Married Divorced Separated/Widowed (If applicable) Name of Spouse, if currently married: First names and ages of children: Education and Occupation Highest degree or year of schooling obtained and major: Current Occupation: Are you happy with your work? Previous Counseling Experience Have you ever seen a counselor before? If yes, when? Major problems discussed: How would you describe your prior counseling experience? PLEASE FILL OUT NEXT PAGE OF CLIENT INFORMATION FORM Page 2 of 7

3 Medical History Any medical concerns we should be aware of? Have you struggled with any kind of addiction, either now or in the past? If yes, what? Have you ever seriously considered or attempted suicide? Have you ever been, or are you now, taking any medications?, If yes, what medication(s), dosage(s), and for what condition. Religious/Spiritual Status If you sometimes attend or are a member of a church/religious organization, please state its name: How often do you attend church? In a short space, how do you feel about God in your life? Current Counseling Desires What do you see is the primary problem you wish to resolve with your counselor? What is it you would like to change? What are you doing now or in the past that has helped? What are you doing now or in the past that has not helped? What kind of support system do you have in place to help with this issue? Page 3 of 7

4 Phone: Office locations: Highlands Ranch Medical Plaza II: 9331 South Colorado Blvd., Suite 60 Website: Highlands Ranch, CO Meridian Business Park near I-25 and Lincoln Ave.: 9540 South Maroon Circle, Suite 250 Englewood, CO Disclosure, Policy, and Fee Agreement Disclosure of Credentials: Degrees: Professional Experience: LPC Licensed Professional Counselor #LPC NCC National Certified Counselor # Registered Psychotherapist #NLC Master of Art in Counseling Denver Seminary Master of Business Administration University of Colorado Bachelor of Science in Business University of Colorado For the past three years, I have provided direct mental health counseling services through in the areas of marriage, couple, individual, family, and group counseling. In addition to my practice at, in the last five years (since 2010) I have provided direct mental health counseling services through Cherry Hills Community Church Counseling Center (individual, marriage, couple, and group), National Institute for Change (individual and group), and Shepherd s Gate Counseling Center (individual and marriage). Certifications: Accreditations: Member: Emotionally Focused Therapy Externship Gottman Institute Level I Marriage Counseling Prepare/Enrich by Life Innovations Inc. Premarital and Marriage assessment and enrichment CACREP - Council for Accreditation of Counseling & Related Education Programs American Counseling Association (ACA) American Association of Christian Counselors (AACC) Colorado Counseling Association (CCA) Dear Counselee, It is my desire to assist and serve you in your counseling needs in the most effective, professional, and ethical manner possible. Counseling services can raise differing expectations, therefore I am providing upfront information and setting clear guidelines for our counseling relationship. You also have certain specific rights which are briefly described herein. Page 4 of 7

5 Regulation of Psychotherapists The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the division of Registrations. The Board of Registered Psychotherapist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) As to the regulatory requirements applicable for mental health professionals: Registered Psychotherapists is a psychotherapist listed in the State s database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain the registration from the state. Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addition Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addition Counselor III (CAC III) must have a bachelor s degree in behavioral health, complete additional required training hours and 2,000 of supervised experience. Licensed Addition Counselor must have a clinical master s degree and meet the CAC III requirements. Licensed Social Worker must hold a master s degree in social work. Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master s degree in their profession and have two years of post-masters supervision. Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. Confidentiality, Ethical Standards, and Counselee s Rights Generally speaking, information provided by and to a client during therapy sessions is legally confidential and cannot be released without the client s consent. There are exceptions to this confidentiality, some of which are listed in section of the Colorado Revised Statutes, and the HIPAA Notice of Privacy Rights as well as other exceptions in Colorado and Federal law. For example: (1) Your counselor is required to report suspected child abuse or neglect to law enforcement. (2) Your counselor is required to report any threat of imminent physical harm by a client, to law enforcement and to the person(s) threatened, (3) If your counselor receives information concerning a serious physical harm to yourself or others, your counselor will take specific actions which may include calling 911 or another appropriate person to initiate a mental health evaluation. (4) Your counselor is required to report any suspected threat to national security to federal officials; (5) Your counselor may be required by court order to disclose treatment information. If a legal exception arises during therapy, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS , et seq.) is available at: In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder. Page 5 of 7

6 You are entitled to receive information from me about my methods of therapy, the techniques I use, and the duration of your therapy (if known), and the fee structure. You can seek a second opinion from another therapist or terminate therapy at any time. If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations to the court concerning custody or parenting issues. By signing this Client Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and you agree not to request that I write any reports to the court or to you attorney, or make any recommendations concerning custody. The court can appoint professionals, who have no prior relationship with family members to conduct an investigation or evaluation and to make recommendations to the court concerning parental responsibilities or parenting time in the best interest of the family s children. Policies We do not provide emergency or 24-hour service coverage. In the event of an emergency, immediately call 911 or go to your nearest emergency room. Services are by appointment only. As this time is reserved exclusively for you, it is necessary to charge for appointments that are not cancelled at least 24 hours in advance. In the event of an emergency, special consideration may be given regarding the cancellation policy. We do not offer the service of filing insurance claims on behalf of our clients. We will, upon request, issue you a billing statement which you may use to file for reimbursement (if available) from your insurance provider. Fees: The objective of this section is to clarify our agreement regarding billing and payment for services provided. Therapy sessions are generally 50 minutes in duration. My standard therapy session fee is $50.00 for an initial therapy session and $ for each session thereafter. In circumstances where fees may present a financial hardship to the client, discounted fees will be considered and discussed in advance of services being rendered. Any discount to the standard fee will be mutually agreed upon prior to services being rendered. Where it is desired by the client, my fee is $ for a 1 ½ hour therapy session (80 minutes) and $ for a 2 hour therapy session (110 minutes). Fees are due at the time of service unless other arrangements are agreed upon in advance. It is preferable that payments be made at the beginning of the session by credit card (credit card authorization herein), check, cash, or online at my web site. In order to keep the therapeutic momentum uninterrupted at the end of the session it is important to handle all business arrangements at the beginning of the session. To this end it is requested: It is preferable to schedule future appointments at the start of the session. If the need arises to cancel an appointment, please contact me at least 24 hour prior to the appointment time to avoid a charge for the session fee or late fee. Page 6 of 7

7 It is preferable to have payments made by credit card by providing the necessary information and authorization herein. Payments can also be made by check or cash (preferably at the start of the session), or pay on-line at Credit Card Authorization: If you would like to have sessions charged to your Visa or MasterCard, fill out the section below and sign. Visa or MC: Card number: Exp. Date: CSC Code (back of card): Billing Zip: Name as it appears on the card: I hereby authorize /Tony Petrelli to charge to the card listed above for fees incurred by me or another authorized individual as listed on this form. I understand I am fully responsible for any unpaid balances. Signature of cardholder Date Equinox Counseling, LLC and Tony Petrelli are not a 24/7 crisis counseling center. IN CASE OF CRISIS OR SERIOUS EMERGENCY: please dial 911 or go to the emergency room of the nearest hospital. If you have any questions or concerns, please feel free to ask your counselor prior to signing this Client Disclosure Fees and Policies Form. By signing below I hereby confirm that I have read and understand this Disclosure, Policy and Fee Agreement and the information contained herein. Further, the information has also been presented to me verbally. By signing below I hereby agree to the terms and fees as described and agree that I am responsible for payment. I understand my rights as a client or as the client s responsible party receiving counseling from Tony Petrelli and Equinox Counseling, LLC. Print Client Name Print Spouse or Partner Name (If receiving joint counseling) (Or Responsible Party) Client Signature Date Spouse or Partner Signature Date (Or Responsible Party) If signed by the Responsible Party, please state relationship to client and authority to consent: Tony Petrelli Date Licensed Professional Counselor (LPC) National Certified Counselor (NCC) Registered Psychotherapist Page 7 of 7

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