The Counseling Center at

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1 Dear Client, Thank you for choosing Winston Salem First. Please read all of this important information. Ke e p this one s he e t for your information. 1- Please complete all forms in full and bring all of the pages with you to your session. If you need a copy of them we will be glad to provide that for you. 2- Winston Salem First strives to offer the best counseling experience possible. For this reason and in consideration to liability issues, we ask that you do not bring your child(ren) to the counseling session unless your child(ren) is the client or involved in the scheduled counseling session. Children over 13 may wait in the lobby by themselves if the parent deems them responsible enough to leave unattended. However, they will not be permitted to care for younger children there. We cannot guarantee the safety of your child(ren) while left unattended. 3- Winston Salem First is pleased to offer affordable rates for counseling. Therefore, should you need to cancel an appointment please do so at least 24 hours before you are scheduled by ing The Counselor Admin at or calling Otherwise you will be charged $50.00 for the missed appointment and will not be able to reschedule until the fee is received. 4- Payments should be made at the time of your appointment. There are three methods in which we receive payment: 1. Cash Deposited in completed envelope and placed in payment box. 2. Checks Made out to WSF, deposited in completed envelope and placed in payment box. 3. Text Giving You will have to s e t up an account one time with this SECURE way of Giving. Send a message to text giving at and follow the instructions. Enter in the payment amount followed by the word counseling (see example below). Then forward your confirmation that shows you paid to If you have any questions about this information please feel free to call the office. Thank you for this opportunity! We look forward to working with you! Winston Salem First

2 CLIENT INFORMATION Please complete this & bring it with you to your appointment. Date of Appointment: Client s Name Age Date of Birth Spouse/Partner Parent/Guardian name(s) Client Address Phone (home) (cell) what number can a recorded message be left? May I you? Yes No *Please note: correspondence is not considered to be a confidential medium of communication so the use is limited to appointments & general information or questions. Place of Work/School: How did you hear about us? Payment Information Fee amount $ Circle Method of Payment: cash check text giving Please list the name of the person(s) that may pay the counseling fees (self, parent(s), significant other, spouse, family member, etc.). Emergency Contact Name Relationship to client: Daytime phone Evening phone Session Fees & Length of Sessions Each session is scheduled for 50 minutes for a $75 fee unless otherwise specified by the counselor. The payment can be in the form of cash, check or text giving. For cash or check put your payment in an envelope (with completed information) & place it in the lockbox hanging in the beginning of the hallway of the counseling offices. Please write the name of the person you are seeing in the blank near specify. Certainly, situations will arise that disallow sessions to occur. Please give a 24-hour notice for the cancelation of an appointment. If the center does not receive notice of cancelation at least 24-hours before the scheduled appointment, you may be responsible for the full price of the missed session. To cancel your appointment or make a new one, please contact your counselor directly or or call at (336) By signing this form you are indicating that you have read the Professional Disclosure Statement as well as agree with the office s terms & guidelines. Client/Guardian Signature Date Staff Signature Date

3 Today s Date: CLIENT INTAKE FORM Client s Name Birth date Ethnicity Parent/Guardian name(s) Age(s) Client Address Phone (home) (cell) What number may I leave a recorded message? Military background? yes no If yes when Family Status: List name, birth date or age, sex, relationship of all children, and whether they live at home with you. Name DOB/age Sex Relationship (step, foster, yours, adopted) At home? 1. YES NO 2. YES NO 3. YES NO 4. YES NO Presently married? yes no if yes, how long? presently separated? yes no Divorced? If yes, when? Who is coming for counseling? Previous counseling? Y N If yes, why? Are you or another family member currently seeing a psychiatrist or another counselor? Y N If so, what family member? If Yes, why? FAMILY MENTAL HEALTH HISTORY In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member s relationship to you in the space provided (father, grandmother, uncle, etc.). Please Circle Alcohol/Substance Abuse Anxiety Depression Domestic Violence Eating Disorders Gambling/pornography/sex addiction Obesity Obsessive Compulsive Behavior Schizophrenia Suicide Attempts Was abused/neglected (physical, sexual, emotional) List Family Member(s)

4 GENERAL HEALTH & MENTAL HEALTH Have you ever had any thoughts or feelings of harming yourself? Y N If yes, when & explain why Have you ever had thoughts or feelings of harming someone else? Y N If yes, when & explain why Do you have any present &/or past problems with gambling pornography sexual addiction spending none If so, when Have you had any significant life stressors or losses in the last year? (Death of a loved one, job, home, etc.) Primary Care Physician: Last exam: Are you currently taking any prescribed medication? Yes No Please list: Have you received any type of mental health services in the past (counseling, psychiatric, hospitalization)? Any past surgeries or medical hospitalizations? why & when Any problems with eating sleeping chronic pain weight changes loss of consciousness headaches Describe any answers checked above Have you ever been sexually, physically, emotionally or mentally abused? yes no If yes by who? Have you ever experienced an abortion (pregnancy termination)? yes no If yes, when? Other medical problems: OTHER INFORMATION Do you consider yourself to be spiritual or religious? No Yes any specific denomination? What values are important to you? What has brought you to counseling now? What would you like to see change in your life? What do you consider to be some of your strengths? What do you consider to be some of your weaknesses? Would you allow a (another if already seeing an intern) counseling intern to be present in your sessions? There is no extra fee for having two counselors in your session and it is an added benefit to you as well. Yes No CONSENT FOR TREATMENT: I hearby give my consent to my counselor,, to provide an evaluation & treatment that we may mutually determine to be appropriate. I understand that services will be rendered in a professional manner, consistent with accepted ethical standards. I understand I will likely gain the most benefit from counseling if I am committed to the process and attend regularly. I understand that no promises have been made to me as to the results of therapy provided by this professional. If at any time during treatment I cannot wait for a return call from my counselor, I agree to contact my psychiatrist, family physician, call Forsyth Medical Center Crisis Response or 911. Print Name Client/Guardian Signature Date

5 Diane M. Warshofsky, MACC, LPCA, LMFT Main Office #: (336) Direct #: (336) Professional Disclosure Statement & Informed Consent Hello & welcome! I am pleased to be working with you as your counselor. This information will inform you about my background & certain aspects regarding our therapeutic relationship. I m able to answer concerns at anytime throughout the duration of the counseling relationship, and thereafter. Qualifications & Experience In 2012, I received a Master s Degree in Christian Counseling from Gordon-Conwell Theological Seminary in Charlotte, North Carolina. I am provisionally licensed as a Professional Counselor Associate (#A9697) and Licensed Marriage and Family Therapist (#1701) in North Carolina. As an intern (900 hrs.) I provided individual, family, & couples therapy as well as groups for women s issues, grief and families that were dealing with impact of addictions. As a professional licensed associate I continued to provide therapy for individuals (children, adolescents & adults), families & couples (married & dating) with the focus of grief/loss, mood disorders, addiction recovery (behavioral, substance abuse, co-dependence), post abortion recovery, life transitions as well as relational issues. Therapeutic Approach & Counseling Services Overall, it is always my goal to create a safe environment, which would allow you to grow in self-awareness and self-acceptance. Through the person-centered modality, I perceive people as resilient individuals who are physical, spiritual, mental, emotional & social beings whom impact & are impacted by the environment & others around them. My eclectic approach draws upon techniques from mindfulness, Gottman Method & narrative therapies. Spirituality is integrated with the perspectives of family systems, psychodynamic, and cognitive-behavioral understandings of how people work & resolve conflicts within life. Whether we discuss the spiritual aspect of life in our time will be up to you. I will enter our relationship with hope and expectation for positive change. It is important, however, that you understand that there are possible risks as well as benefits of counseling. Risks might include uncomfortable levels of feelings like sadness, guilt, anxiety, or anger. Sometimes, relationships with others can take unaccustomed directions that may feel awkward at first. As a counselor, I am unable to prescribe medication. In the event that a referral is necessary, a medical doctor or nurse practitioner will appropriately evaluate the situation and make their suggestions for treatment. A diagnosis (DSM 5), required by insurance companies, is a description of a pattern of behaviors. It is important to be aware that a diagnosis does become part of your permanent record. I do not work with people whom I cannot help using the resources and skills I have available, and will in such cases offer a referral to another therapist who may be better equipped to help. In the event that you wish to reach me between sessions, please call the phone number listed above. With the exceptions of holidays and weekends I routinely check messages and will get back to you within 24 hours. In the event of an emergency or crisis please call the following: Forsyth Medical Center Crisis Response or 911. Fee Schedule & Length of Session The designated fee for my services is $ The fee may be paid with cash, check or text giving which is due at the time of services. It is our desire at Winston-Salem First to not turn anyone away that may need counseling. The Administrative Admin will need to be contacted directly if finances are a concern or call ). Place the payment in the lock box with a mail slot on top down the hall from my office hanging on the wall. We do not accept insurance at this time. Certainly, situations will arise that disallow sessions to occur. However, it is my goal that the counseling sessions do began and end on time. Please give a 24-hour notice for the cancelation of an appointment. If I do not receive notice of cancelation at least 24-hours before the scheduled appointment, you may be responsible for the full price of the missed session. If you need to cancel your appointment or make a new one, please contact us at or call (336)

6 Employees of WSF (Winston Salem First) and their families (immediate family of the employee) Employees, Students and their families (immediate family of employee or student) of WSCS (Winston Salem Christian School) Employees, students and their families are offered to pay a discounted fee for counseling as a benefit in the amount of $25.00 per session. Employees and students that are mandated to attend counseling will not be required to pay a fee for counseling unless they go over 6 sessions. At that time, counseling is no longer mandatory, but they may pay the $25.00 fee per 50 minute session if they wish to continue with counseling. Consultation & Restrictive Licensure As a LPCA, I am pursuing full licensure credentials. Until I receive a LPC, my counseling services are supervised by Chris Rodriguez, MA, LMFT. His private practice location is 100B Stadium Oaks Drive, Clemmons, NC 27012; (336) In addition, the staff of The Counseling Center may also be consulted. My sessions may be audio taped/videotaped; however, this would ONLY be conducted upon your consent. If you provide consent for sessions to be recorded, your confidentiality will be maintained, and no identifying information will be included in the recording. You need not consent to recording of sessions to receive counseling services. Counseling Relationship & Confidentiality Although our sessions may be very intimate psychologically, it is important for you to realize that we have a professional relationship rather than a social one. Our contact will be limited to the sessions you arrange with me. It is also vital for you to know that if I see you in public, I will protect your confidentiality by greeting you only if you greet me first. I regard the information you share with me with the greatest respect, so I want us to be as clear as possible about how it will be handled. All information that we share as well as my records of conversations is confidential with the following exceptions: (1) you direct me to tell someone else, (2) I determine that you are a danger to yourself or others, (3) there are indicators of child or elder abuse, (4) or I am ordered by a court to disclose information. Please bring any questions you have about confidentiality to my attention. When the relationship of the couple is the focus of the therapy keep in mind that a No Secrets approach will be implemented. Meaning that if one of the individuals of a couple shares pertinent information their significant other is not aware of, the therapist will explore the need to share this for the well being of the relationship. The therapist will aid this individual in the process of how, when & what is shared in the couple s session. Questions or Concerns I encourage you to discuss any questions or concerns you may have regarding our work. If should you feel I am in violation of any codes of ethics, please refer to ACA Code of Ethics (http://www.counseling.org/resources/codeofethics/tp/home/ct2.aspx). If I am not able to resolve your concerns, you may contact my supervisor, Chris Rodriguez at You may also report complaints to the North Carolina Board of Licensed Professional Counselors at P.O. Box 1369, Garner NC, 27529, , fax: , ; North Carolina Marriage and Family Licensure Board at: PO Box 37669, Raleigh, NC, 27627, , for clarification of clients rights. I look forward to working together in a counseling relationship. If you have any questions regarding the information in this document or any other part of the counseling process, please feel free to let me know. Acceptance of Terms: by signing below you are acknowledging that you have read, understood and agree with the conditions outlined. Client s Signature Date Therapist s Signature Date Parent/Guardian Signature Date

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