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1 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 I want you to be well informed regarding your prospective counselor s credentials and level of experience before your first appointment. Please read the following information: About Dr. Yee Dr. David Yee is a licensed Psychologist and independent contractor with North Valley Christian Counseling. Dr. Yee earned his Psy.D. and M.A. in clinical psychology from Argosy University and his B.A. in psychology from Arizona State University. Prior to joining the team at NVCC, Dr. Yee gained experience providing therapy and assessments at Southwest Behavioral Health Services and West Valley Family Development Center in addition working with adjudicated youth at the Arizona Department of Juvenile Corrections. He has experience in treating children, adolescents, adults and their families. Prior to becoming a psychologist, Dr. Yee spent ten years working with children, adolescents, and their families as a youth pastor. Dr. Yee is not a medical physician and does not prescribe medication. Informed Consent In order to assist you in understanding the responsibilities and expectations involved in the counseling relationship, please read and sign the following informed consent. At the close of our initial session you may request a copy for your personal reference. Psychological Services The psychotherapy process is different for every client and outcomes vary. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings because the process often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. Throughout process of psychotherapy clients may encounter unintended consequences as a result of behavioral change. In the case of marriage and family counseling, interpersonal conflict can increase initially. Of course, the potential for a divorce is always a risk in marital counseling. Treatment process and Rights Your counseling will begin with one or more sessions devoted to an initial assessment so that your counselor can get a good understanding of the issues, your background, and any other factors that may be relevant. Following your initial consultation, I may recommend specific psychological testing in order to better facilitate an appropriate diagnosis or treatment plan. When the assessment process is complete, I will discuss ways to treat the problem(s) that have brought you into counseling and develop a treatment plan. You have the right and obligation to participate in treatment decisions

2 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 and in the development and periodic review and revision of your treatment plan. You also have the right to refuse any recommended treatment or to withdraw consent to treat and to be advised of the consequences of such refusal or withdrawal. If there is ever a time when you believe that you have been treated unfairly please talk with me about it. It is never my intention to cause this to happen to my clients, but sometimes misunderstandings can inadvertently result in hurt feelings. I want to address any issues that might get in the way of the therapy as soon as possible. This includes administrative or financial issues as well. Financial Agreement Payment is expected at the time the service is rendered. By signing this document, you are agreeing to pay for the services rendered and any additional expenses that may be accrued in collecting said fees. Current Fee Schedule Intake Assessment $125 Psychotherapy (55 minutes) $125 Psychological testing (See separate fee schedule) Missed Appointment Fee $50 A $50 missed appointment fee will be assessed for appointments that are missed without 24-hour advanced notice of cancelation. There will be a $25.00 fee for checks that are returned as non-sufficient funds or non-payable. Other requests for professional services such as letter writing or attending meetings will be billed at the hourly rate, prorated in 15 minute increments. I reserve the right to change my fee with a 30-day notice. You have the right to be informed of all fees that you are required to pay and my refund and collection policies. Please discuss these with me if your have a concern. If there is over payment on the account, please allow 15 business days upon written request for refund to be processed. I reserve the right to adjust or waive certain fees at my own discretion. Availability of Services I do not offer 24-hour emergency response services. If you experience an emergency, please call 911. If you experience a mental health crisis, please contact a crisis response team at one of the numbers listed below. If you leave a message for your provider your call will be returned by the end of the next business day. Empact Banner Helpline Magellan Privacy, confidentiality, and records I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting

3 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request. Requests for records may take up to 10 business days for fulfillment. Ordinarily, all communications and records created in the process of counseling are held in the strictest confidence. However, there are some exceptions to confidentiality defined in the state and federal statutes. The most common of these exceptions are when there is a real or potential life-threatening emergency, when there is substantial evidence of abuse or neglect of a vulnerable person, by court order, or for consultation. I reserve the right to refer a client to another therapist or appropriate resource if the needs presented in therapy are inappropriate for the counselor s skills or experience. PARENTS & MINORS While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child s agreement, unless I feel there is a safety concern, in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised. Consent for evaluation and treatment Consent is hereby given for evaluation and treatment under the terms described in this consent document. It is agreed that either of us may discontinue the evaluation and treatment at any time and that you are free to accept or reject the treatment provided. In the case of a minor child, a custodial parent or legal guardian of the child must authorize services for the child under the terms of this agreement. Client Name Signature Date Parent or Legal Guardian (If client is under 18) Parent or Legal Guardian Signature Date

4 Notice of Privacy Practices 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please speak with your counselor/psychologist. This Notice of Privacy describes how this office may use and disclose your protected health care information to carry out treatment, payment, or health care operations and for those other purposes that are permitted or required by law. It also describes your rights to access and control you protected health information. Protect Health Information (PHI) is information about you that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. This office is required to abide by the terms of this Notice of Privacy Practices. This office may change the terms of the notice at any time. Upon your request, you will be provided with any revised Notice of Privacy Practices. Under most circumstances, this office is required by law to obtain your written permission for any disclosure (electronic, written, or oral communication) of identifying information about you and your treatment. If you or your counselor/psychologist believe that communication with a third party would be beneficial (for example, previous psychotherapists, physicians, school personnel, court system), you will be asked to sign a release of information to that effect. PAYMENT: Your PHI may be used as needed to obtain payment for you mental health care services. Please be aware that you PHI may be electronically submitted (i.e., sent via fax or the Internet) for these purposes. If you choose to use insurance to pay your healthcare bills, you will be asked to sign a release of information to your insurance company for purposes of authorization of sessions and payment. Examples of information sometimes required by insurance companies to approve or pay for services include your name, diagnosis, treatment plan, prognosis, and, if your chart is chosen for review, notes that document your progress in treatment. If you are being seen through Workers Compensation, you will be asked to sign a release of information to that organization for purposes of authorization of sessions and payments. Examples of information required by Workers Compensation to approve and pay for services include your name, diagnosis, treatment plan, prognosis, and notes that document you progress in treatment.

5 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 If Individual client accounts are left unpaid for more than 90 days, your name, address and phone numbers, and attendance in treatment may be given to a collection service for purpose of collection. HEALTHCARE OPERATIONS: This office may use or disclose your PHI as needed in order to support the business activities of this practice. This office may share your PHI with third party business associates that perform activities such as billing and accounting services for the practice. Whenever an arrangement is made between this office and a business associate that involves disclosure of your PHI I will have a written contract that contains terms that will protect the privacy of your PHI. There are some circumstances that require your counselor/psychologist to disclose your PHI, even without your consent. The following are examples of the types of uses and disclosures of your PHI that this office must make. If appropriate, your counselor/psychologist will make efforts to communicate imminent disclosures to you prior to their occurrences If your counselor/psychologist suspects that a child has been hurt physically or sexually, or neglected (this includes witnessing violence in the home), Child Protective Services will be contacted. If an adult is living in a relationship that is violent, Adult Protective Services will be contacted. If you are at high (imminent) risk for suicide, communication with appropriate persons (e.g., hospital personnel, police officers) to ensure your safety may occur. If you report to your counselor/psychologist that you intend to kill another person, your counselor/psychologist will contact the targeted person(s), appropriate persons to ensure your safety, and local law enforcement. If a judge issues a court order, your PHI may be disclosed to the relevant judicial body.

6 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION I,, understand that as part of my health care, the office of North Valley Christian Counseling originates and maintains the paper and/or electronic records describing my health history, symptoms, diagnoses, treatment, and any plans for future care or treatment. I understand that I information serves as: A basis for planning my care and treatment A source of information billing A means by which a third-party payer can verify services I understand and have been provided with a copy of the Privacy Notice that provides a more complete description of information uses and discloses. I understand that I have the following rights and privileges: The right to review the notice prior to signing this consent The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or office operations. I understand that this office is not required to agree to the restrictions requested. I understand that I may revoke this request in writing, except to the extent that action has already been taken. I also understand that by refusing to sign this consent or revoking this consent, North Valley Christian Counseling may need to refuse to provide treatment by Section of the Code of Federal Regulations. I further understand that the office of North Valley Christian Counseling reserves the right to change this notice and practices in accordance with section of the code Federal Regulations. Should this office change this notice, a copy will be sent to the address I have been provided. I understand that as part of this office s treatment, payment, or office operations, it may become necessary to disclose my Personal Health Information to another entity, and I consent to such disclosure for these permitted purposes, including disclosures via fax. I fully understand and accept the terms of this content. Client Name Signature Date Parent or Legal Guardian (If client is under 18) Parent or Legal Guardian Signature Date

7 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 Consent for Treatment of a Minor Minor s Name: DOB: Address: I, am the parent / legal guardian responsible for medical and/or mental health decisions for the above named minor. The therapeutic value of confidentiality has been explained to me and I understand my child /adolescent will be treated with the best judgment possible. I hereby acknowledge that I am willing for my child / adolescent to receive mental health services from North Valley Psychological and Counseling Services, also known as North Valley Christian Counseling. Is there a custody order in effect for this minor? Yes No If yes, please indicate Sole Joint Custody List any restrictions: Printed Name of Father or Legal Guardian Phone Date Signature of Father or Legal Guardian Printed Name of Mother or Legal Guardian Phone Date Signature of Mother or Legal Guardian

8 Information Questionnaire for Minors 602%548%8508(MainOffice) 623%670%2927(DirectLine) 17505N.79 th Avenue,Suite410 Glendale,AZ85308 Minor s/client s Name: Today s Date: Address: Home Phone#: City: State: Zip: Date of Birth: Age: Gender: Person completing form: Relationship to Minor: Mother s Name: Date of Birth: Address: Employer: Contact number: Father s Name: Date of Birth: Address: Employer: Contact number: Other adults legally or medically responsible for the client: Name: Relationship to Minor: Client s school: Grade: Phone #: Family Physician: Phone #: Emergency Contact Person: Phone #: Describe any current medical problems: List any medications currently taken by minor:

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