Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no

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1 Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX Office: (972) Client Initial Interview Form Full Name: : Gender: Male Female of Birth: Address: City: State: Zip: May I mail to this address? yes no Phone: (h) (C) May I contact you at these phone numbers? yes no May I leave messages at these phone numbers? yes no May I you? yes no Marital Status: Married Never Married Engaged Separated Divorced Widowed If divorced, what year? If widowed, what year? Religious preference: Highest Level of Education: Employer: Occupation: How long have you worked there? _ Primary Physician: Phone: Who should I contact in case of an emergency? Name: Phone: Financially responsible person s information: Name: Relationship to client: Phone (if different): _ Address (if different): How were you referred to our office?

2 List any significant health problems (i.e., diabetes, asthma, thyroid problems): List any prior hospitalizations (date, reason, treatment type): List any medications you are taking & dosage: Have you ever been in therapy? yes no If yes, please give name of therapist, dates, and issues discussed: Are you currently under the care of a physician and/or psychiatrist? yes no If yes, please give name of physician/psychiatrist, duration and reason: Have you considered or attempted suicide? yes no If yes, please briefly explain: Have you considered or attempted homicide? yes no If yes, please briefly explain: What is the major concern bringing you into counseling? List any other concerns you may have:

3 Have you experienced any of the following? Depressed mood most of the day or nearly every day? yes no Diminished level of interest in most or all activities? yes no Any change in appetite? yes no Any change in weight? yes no Any changes in sleep patterns? yes no Fatigue or loss of energy? yes no Feelings of worthlessness or guilt? yes no Difficulty thinking or concentrating? yes no Irritability or violent behavior? yes no Any hyperventilation, palpitations or intense fear? yes no Any history of food binging? yes no Any history of purging or unhealthy food restrictions? yes no Any history of excessive alcohol and/or drug use? yes no Any traumatic events? yes no Any academic difficulty? yes no Does anyone in your family suffer from alcoholism, eating disorders, depression, addictions, anxiety, mood disorders, phobias, suicidal behavior, drug/alcohol dependence, etc.? yes no If yes, please explain:

4 Family of Origin (parents/guardians, siblings): Name Age Relationship Immediate Family Members (spouse, children): Name Age Relationship Any additional comments? What are your goals for therapy? What do you hope to gain? I certify that this information is true to the best of my knowledge. I agree to notify you of any changes in the information above. Client Signature Parent/Guardian Signature (if under 18) Counselor Signature

5 Client Informed Consent The Vale provides professional counseling, Biblical counseling, and spiritual guidance. Nancy Thomas serves as a Licensed Professional Counselor Intern (License number: 73992), supervised by Jennifer Perla, LPC-S (License number: 18968). Nancy graduated from Dallas Theological Seminary with her Master of Arts in Counseling and from the University of Texas at Dallas with her Bachelor of Arts in Psychology. Therapeutic Relationship: Our approach to counseling takes into account the spiritual, psychological, social, and biological dimensions of the client. The counseling relationship will be characterized by mutual respect and cooperation. We will, together, pursue the goals that are set at the beginning of the counseling process for appropriate growth and development. Our ultimate goal is that you are able to manage any issues that arise without therapeutic assistance or intervention. The therapeutic relationship is a professional relationship in which appropriate boundaries must be maintained. Your therapist cannot, therefore, be expected to be involved in any social, friendship, and/or mentoring relationship outside of the therapist s office. Confidentiality: Everything that is communicated between the client and counselor is confidential and every effort will be made to ensure confidentiality is maintained. Please note, however, that there are exceptions to confidentiality, in which case information may be disclosed to the appropriate authorities, agencies, or individuals. The exceptions are as follows: If the therapist has reason to believe that you may harm yourself or others. If the therapist has reason to believe that you are involved in or have knowledge of abuse, neglect or exploitation of a child, an elderly person, or a disabled person. If there is an ordered disclosure by state or federal courts If you sign a release form granting permission to designated third parties to receive information. In collaboration with supervisors, peer therapists, and other counseling interns. Counseling Process: The counseling process comes with its risks and benefits. Since therapy involves discussing unpleasant aspects of your life, it may at times cause distress, sadness, anger, guilt, frustration, etc. Despite the negative emotions you may face through the process, it is important to note that psychotherapy has many benefits. It often helps the client have better relationships, solve specific problems, and reduce feelings of distress. Please remember, however, that it is impossible to guarantee and specific results regarding your counseling goals. We will work together, both in and out of session, to achieve the best results and meet your goals as best possible. I use a combination of Cognitive Behavioral Therapy, Solution-Focused Therapy, Adlerian Therapy, and Gestalt Therapy to assist you in achieving your goals. Fee Agreement: Sessions are 45 to 50 minutes in length, unless otherwise agreed upon. Fees are payable at the time of service. Your fee is $ for the initial intake session, and $ for every session thereafter. Your regular fee will be charged for any additional professional services rendered at your request, such as phone contacts over 3 minutes, consults with other professionals, etc. Preparation of special forms, reports, court time, etc. will be billed at the rate of $ per hour. We accept cash, check, VISA, MasterCard, American Express, and Discover. The usual, customary, and reasonable fee for individual counseling at this level is $ per session. We do have a sliding scale available for those who can prove

6 financial hardship. Please speak to me if this is a need. It is The Vale s policy that no one is turned away because of lack of payment; however, this must be pre-arranged. Your payment is to be paid in full at the time of each session. Fees are subject to change every six months. No-Show & Cancellation Policy: Your appointment time has been reserved for you. Twenty-four hour notice is required for cancellation or you will be charged a late cancellation fee of a full session fee. You may leave a message with our office 24 hours a day, 7 days a week. Notice of Privacy Practices Acknowledgement: I understand that under the Health Insurance Portability & Accountability Act of1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you agree then you are bound to abide by such restrictions. In the event of my death or incapacity, a licensed therapist in Dallas County, Texas will manage your records. To contact our governing board, you may call or write to Complaints Management and Investigative Section, P.O. Box , Austin, TX Court Testimony: If requested to testify or subpoenaed to appear in court, Nancy Thomas requires a minimum fee of $ to be paid prior to the court appearance. Emergency: In the event of a potentially life-threatening emergency, please go to your local emergency room or call 911. For non-life threatening emergencies, you may contact me or leave a message at Calls will be returned as soon as possible. Your signature constitutes your informed consent to enter the counseling relationship, and that you have read and understood the process of therapy, the limitations of confidentiality, and possibly risks of counseling. Client Signature Parent/Guardian Signature (if under 18) Counselor Signature

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