South Georgia State College

Size: px
Start display at page:

Download "South Georgia State College"

Transcription

1 South Georgia State College Counseling Services Policies & Procedures February, 2013

2 INTRODUCTION This Policies and Procedures Manual for the South Georgia State College Counseling Office is intended as a reference for all staff and as an introduction for counseling services provided. The policies and procedures in this manual have been compiled to assist students in receiving counseling services, but is not an all inclusive document and is subject to change. Students unsure of the appropriate procedure to follow and/or with a situation not covered by this manual should contact the Counselor s Office for clarification and guidance. MISSION STATEMENT The mission of the Counseling Office is to provide short term counseling and support services to meet the personal, social, and educational needs of students enrolled at SGSC. SERVICES OFFERED Consultation and intake sessions will determine if the student will receive short term individual counseling or a referral to an outside agency. ELIGIBILITY FOR SERVICES AND GUIDELINES FOR OFF CAMPUS REFERRALS 1. Students must be enrolled in at least four (4) academic hours to receive services. 2. Treatment for psychiatric disabilities such as bipolar disorder, schizophrenia, and recurrent serious depression should receive their psychiatric follow up and psychotherapy off campus since these conditions require long term follow up. 3. Treatment for alcoholism or drug addiction will be referred to programs off campus. AA meetings sites are provided for students who are just beginning the process of recovery to supplement their off campus treatment. 4. Students diagnosed with anorexia must have a primary treatment provider in the community and a written treatment contract with that provider which spells out the role of the Counselor and authorizes close communication between the primary counselor, parents, student, and the South Georgia State College Counselor. Services will be limited to supportive crisis intervention and assistance with issues related to academic performance and adjustment to college. Students with untreated and/or previously undiagnosed anorexia will be informed that an outside evaluation must be obtained. 5. Students who identify themselves as seeking long term therapy (who often mistakenly conclude this is covered by their tuition payments) should be referred to off campus providers, with information about those who utilize a sliding scale fee. 6. Students who complete a course of short term counseling/therapy and as a result identify a need for longer term work may be referred off campus for individual work or to a Counseling Center support group for additional assistance.

3 INFORMED CONSENT Georgia s law requires that during an initial session the student should be informed about confidentiality and exceptions to confidentiality contained in state statutes. All new students are asked to review and sign a form entitled Counseling Intake Informed Consent Form that explains services offered, confidentiality, and limits to confidentiality. Occasionally a student will decline to sign the form. If the student verbally indicates an understanding of the material contained in the form and a desire to receive services, the counselor should document this in the progress notes along with the student's concerns about signing the form. The counselor may then proceed to work with the student, providing counseling and/or assessment and referral. POLICY REGARDING SERVICES TO FACULTY AND STAFF Counseling Services offer consultation to faculty and staff pertaining to problem resolution and goalsetting in the interest of the education of South Georgia State College students. However, the Counseling Office, in accordance to code 1.17 of the American Psychological Association's code of ethics, is not able to offer services for personal use among South Georgia State College faculty and staff because of the conflicting relations that may arise. REFERRALS TO OFF CAMPUS PROVIDERS OF PSYCHOTHERAPY The Counseling Office maintains a list of area mental health professionals in private practice and area mental health clinics. Information regarding sliding scale fees is included when applicable. Referral to any of these professionals does not constitute an endorsement and students are counseled that they may have to research to find a therapist that would be suitable for them. OFF CAMPUS REFERRALS FOR PSYCHOTROPIC MEDICATION Students with psychotic illness and bipolar disorder will be referred to local mental health clinics or psychiatrists in private practice for medication management. Students with depression, ADHD, and anxiety disorders may be referred to their primary care physician or to a psychiatrist near their home for medication evaluation and management. GENERAL COUNSELING Each individual is entitled to privacy in his/her work with a counselor. All contacts with a counselor are confidential. Written permission is required for Counselor to release information to others. A court order may require an exception to the lawful protection of individual legal rights to privileged communication with a counselor or psychiatrist. If it becomes clear in the counseling session that there is a real danger to one or to others, the Counselor is required to take action. Reports of abuse of children or others unable to care for themselves will also require some action to be taken. Confidentiality laws do not apply in these cases.

4 COUNSELING OFFICE RECORDS 1. Intake Notes Students are asked to fill out New Client Intake paperwork prior to their first counseling session. This intake paperwork includes an informed consent form, student s demographic information, concerns he or she would like to address during the counseling session, and a psychological symptoms and distress rating scale. 2. Session Notes A progress note should be written after each subsequent session. Progress notes are descriptions of on going counseling work. It is advisable to write descriptive progress notes rather than impressionistic ones, because these notes may be open to the student's review. Care should be taken to protect the identity of third parties that the student may discuss and highly sensitive issues should be described in language that protects the student's privacy. Each progress note should include a brief statement regarding the focus of further work. All corrections made are to be crossed out with a single line, written clearly, initialed, and dated in ink. 3. Case Summaries Case summaries are written at termination. Summaries should indicate how many sessions the student was seen, the presenting problem, the course of treatment, and final recommendations or disposition. 4. Storage and Disposal of Records Counseling Office records are stored in central, locked files. Records are kept for 7 years, and then destroyed via shredding. 5. Third Party Concerns A number of people come to the Counseling Office because of their concern about someone else. When this occurs a counselor will dictate a note labeled consult and place it in the file of the person who is the object of concern if the file exists. If the person is not yet a student of the Counseling Office, the counselor will leave the consult note in a file, if the person becomes a student. RELEASE OF INFORMATION POLICY: 1. All communication between a student and a counselor is confidential and will not, except under the circumstances explained below, be disclosed to anyone outside of Counseling Office unless written authorization to release information is given. A Release of Information Form will need to be signed in order for the Counselor to release information to anyone. A record is kept of a student s work with the Counseling Office. It contains information a student has provided to the counselor in writing as well as counseling notes from student sessions. A student s record never leaves the Counseling Office and never becomes a part of the educational record. The record remains in the Counseling Office for a period of seven years following the student s last visit; at that time, it is destroyed.

5 2. Most limits to confidentiality are to ensure safety. If there is evidence of imminent danger of harm to the student or other(s), the Counselor must take action. If a student describes abuse of a child or elder, the information will be reported to the appropriate agency. It is possible a court order may require release of privileged communication. 3. Counseling information cannot be released to the following without the student s consent: A. parents or guardians, spouse, siblings, or significant other B. another doctor, lawyer, or health organization C. insurance company, disability payment source, or state agency Procedure: A student may review his counseling record in the confines of the Counseling Office with a counselor and only by appointment. A student wishing to grant release of information to another party must complete the Release of Information form. There is no charge if records are released directly to another physician or health care facility, or another entity of South Georgia College. A summary of a student s counseling record may be prepared by a student s counselor. A summary is a written document created by a counselor based on the contents of the chart describing the counseling episode. Records may be faxed or mailed. A cover sheet or letter must be affixed to accompany all documents. The legal counsel of South Georgia State College may wish to review cases involving probable legal action before the information is released. In a legal case, the whole chart is copied at the written request of the legal counsel. The counselor will not release any medical information obtained from another clinic, hospital, or private physician if marked not for secondary disclosure. Counselor will not release records pertaining to alcohol/drug use, mental health, HIV/AIDS, abortion, and sexual assault unless the written consent is signed. In cases of immediate transfer by ambulance or police of a student to any emergency facility or hospital, appropriate information can be sent with the student, including photocopies of clinical notes and identification information. This material should be provided for continuity of care. All attempts will be made to contact the emergency contact person(s) supplied by the student s verbal request. Pages of the chart with the stamp re disclosure is prohibited may accompany records released by the records technician. The recipient of the information is then prohibited from using the information for other than the stated purpose and will prevent disclosure to a third party.

6 TARASOFF WARNINGS Under Georgia law, when a student makes what a counselor considers to be a legitimate threat toward a third party, the counselor must warn the identifiable potential victim, if there is one (there is no requirement to attempt to warn a whole class of people) and the nearest police department. A verbal warning should be made to the intended victim. The therapist should also fully document the warning to the intended victim in the student's case record. If the victim cannot be reached by phone or in person, a letter should be sent to the intended victim by registered mail, return receipt requested. If there is any question regarding the intended victim understanding or taking the threat seriously, a follow up letter, return receipt requested is also suggested. The initial report to the police may be oral but should be followed by a written report, generated by either the police or the therapist. MANDATED REPORTING ISSUES In Georgia, as in most states, all licensed mental health professionals are mandated to report abuse and neglect of children under age 18, abuse and exploitation of disabled persons, and abuse and exploitation of persons over the age of 60. Counselors can call the appropriate agencies and describe a questionable situation and be advised as to whether it needs to be reported. College policies also require anonymous reports of sexual assaults experienced by students or on the campus to be made to the Dean of Students. STUDENT COMPLAINT/GREIVANCE POLICY A. Student complaints are handled largely through the existing chain of command. Given the existing laws regarding confidentiality and psychological/health services, a counselor/health service provider is restricted in terms of what he or she can disclose. If a student has a complaint about an employee or consultant of the Counseling Office, he or she is directed to speak with that employee s director, or if necessary, the immediate supervisor of the employee. The complaint should initially be lodged informally by speaking with someone in the department. However, the complaint can be lodged more formally in writing first to the Director within five (5) working days of the incident. The written complaint or grievance should include a description of the incident, date, time, and persons involved in the complaint. B. The director shall then respond to the grievance in writing within five (5) working days of the date that the grievance was signed and filed. If the student is not satisfied with the outcome of that discussion or response, he or she is directed to the next higher level of administration. In each case, careful consideration is given to the emotional stress the student may already be in as well as any complications arising from a possible mental or physical illness. If a complaint comes from a nonstudent, it is handled administratively first by the Director, then by the Dean of Students. The Director reserves the right to consult with the General Counsel of the College around issues or complaints that may have legal implications. Documentation of a student complaint would become part of the confidential record.

7 C. Any complaints, if found to have merit, will be used in the supervision of the employee involved to improve the person s skills and function. ALCOHOL AND DRUG POLICY Please refer to the South Georgia State College Handbook AFTER HOURS COUNSELING EMERGENCIES Douglas Campus Public Safety Police Department or 911 Coffee Regional Medical Center Unison Behavioral Health Georgia Crisis & Access Line Waycross Campus Police Department or 911 Mayo Clinic Health System Unison Behavioral Health Georgia Crisis & Access Line MANAGING SUICIDAL OR OTHER AT RISK STUDENTS Students experiencing major crises may be seen daily until the crisis is past. Students are given information on 24 hour crisis programs. Introductions to other staff should be made, so the student has other contacts at the Counseling Office and the student should be encouraged to utilize services as needed. The counselor and the student should develop written plans for structuring time and coping with emotional upset between sessions. Prompt psychiatric consultation should be arranged. Sources of emotional and social support should be identified and utilized. It may mean contacting the student's parents, preferably with his or her permission. However, if the risk is judged to be significant, parents or other family members may be contacted without the student's permission, under Georgia law. Careful monitoring of suicidality and documentation of this should occur at each contact. Substance abuse issues should be vigorously addressed. Means of self harm (medications, firearms) should be identified and removed. Written contracts for personal safety may also be utilized. If the crisis is very severe or does not result fairly quickly, hospitalization should be considered. A Crisis is defined as: 1. A person who had conveyed verbally or behaviorally that he/she is in crisis 2. A person who is disoriented and confused or lacks contact with reality 3. A person who disrupts college operations 4. A person who is in imminent danger of hurting him/herself

8 Procedure for voluntary crisis assistance: Student will be asked for an appropriate contact person to come to campus and take the student to the ER for a medical evaluation. If contact person is unavailable, then Public Safety (Douglas Campus) or Police Department (Waycross campus) will transport student to ER for medical evaluation. Staff will remain with student until their contact arrives or Public Safety (Douglas Campus) or Police Department (Waycross campus) transports student to ER. Counseling Staff will make an appointment with student for follow up upon their return to SGSC. Procedures for non voluntary crisis assistance: Public Safety (Douglas Campus) or Police Department (Waycross campus) will transport student to the ER for medical evaluation. Staff will call emergency contact for student as needed/requested Counseling Staff will make an appointment with student for follow up upon their return to SGSC. *Under no circumstances shall a staff/faculty member transport a student in their personal vehicle. LEARNING DISABILITY EVALUATIONS The Counseling Office does not have the resources to provide assessment or formal documentation of learning disabilities to students. A list of local psychologists qualified to provide this service is available. Students are also provided information regarding which tests would customarily be used in a learning disability assessment and the price range of such an assessment. Students are advised to check with their health insurer to determine what portion, if any, of the evaluation would be covered. Documentation guidelines follow the Board of Regents of the University System of Georgia criteria. CONFIDENTIALITY Protecting the confidentiality nature of the counseling setting and services is top priority. The Counselor may divulge information only with the student's consent and only the minimum amount necessary. The Counselor will write progress notes in respectful tones and assume the notes may be read by the student and could become part of legal proceedings. The counselor will set limits on inappropriate requests by administrators and parents for information and will routinely advise students of the legal limits to confidentiality. COURTESY NOTES TO FACULTY Counseling Office may occasionally write notes and/or messages to faculty, with the student's permission, to advise faculty that a student is having a personal problem, has suffered a trauma, is experiencing a depressive episode and receiving treatment, etc., and to request that faculty engage in a dialog with the student regarding the impact of this on his or her functioning in the student role. These notes are professional courtesies and collegial requests that the student be offered some additional help and/or consideration. They do not constitute formal documentation of a disability which would qualify a student for formal accommodation under the Americans with Disabilities Act.

9 HOURS OF OPERATION Counseling Sessions are available by appointment only. Once a referral form has been completed and turned in to the Counseling Office for review, a Counseling Intake session will be scheduled. Referral forms can be found online, under SGSC Quick Links and Counseling Services, or outside the Counseling Office. ALL REFERRAL FORMS ARE TO BE TURNED IN TO THE COUNSELING OFFICE. Please do not referral forms. Referral forms may be placed in the mailbox located outside the Counseling Office.

10 APPENDIX Counseling Referral Form Informed Consent Form...13 New Client Intake Consent to Release Form.23 Verification of Attendance...24 Unison Behavioral Health Services Authorization to Use & Disclose Health Info Titanium Scheduling Directions for Use 28

11 Counseling Referral Form SGSC Student: Please read the following information and answer where indicated. FULLY complete, print, and turn this form into the SGSC Counselor. 1. The first meeting with the counselor will be for a consultation to determine what services will be most helpful to you. During your consultation, you will be asked to complete an Intake Form. Upon completion of the Intake Form, and, depending on your individual concerns, the counselor may suggest several possible courses of action. If personal counseling is recommended, it will be necessary to schedule a regular time to meet with the counselor. 2. All information discussed during the counseling session(s) is strictly confidential. However, due to state law some exceptions apply including: A. Imminent danger of harm to self or others B. Knowledge of physical abuse, sexual abuse, or neglect of a child or an elderly person C. Court ordered subpoenas 3. Appointments usually begin on the hour and last for 50 minutes. 4. If you are unable to keep your counseling appointment, please contact the counselor 24 hours in advance to cancel or reschedule. If the counselor is unable to meet with you during your scheduled time, you will be contacted at the telephone number you provide. I have read and understand the conditions listed above and agree to them, Signature Date Counselor s Signature Date Directions: Use an X to indicate when you are NOT available for a counseling appointment. MONDAY TUESDAY WEDNESDAY THURSDAY 9:00 9:50 a.m. 10:00 10:50 a.m. 11:00 11:50 a.m. 12: :50 p.m. 1:00 1:50 p.m. 2:00 2:50 p.m. 3:00 3:50 p.m. 4:00 4:50 p.m. 5:00 5:50 p.m. If your situation is an emergency requiring immediate attention, please contact Campus Police at (Douglas Campus) or 911! Personal Information Form Full Name: Called by: (OVER)

12 Date: Address: Phone Number I can use to contact you to schedule an appointment: - - Cell Phone #: Student ID #: DOB: - - Age: Sex: F M Classification Relationship Status Ethnicity (optional) Freshman Single Separated Asian Hispanic Sophomore Married Divorced Black Other Other Cohabitant Widowed Caucasian Major: GPA at SGSC: Are you on Academic Probation? Yes No Have you previously had counseling? Yes No Have you previously received counseling at South Georgia State College? Yes No Are you currently receiving counseling services at another location? Yes No If you answered yes ----when, how long, and for what purpose? Please list any on-going health problems: Specify any medications currently taken: Have you experienced any recent or important loss? Yes No If you answered yes ---Please specify: Please identify the concern(s) that you would like to address in counseling. (OVER)

13 Counseling Intake Informed Consent Form The Counseling Center provides services at no cost to currently enrolled students with 4 or more hours at South Georgia State College. Students must be attending class at the time counseling is sought. Academic, career, and personal counseling are provided on an appointment basis. Consumer Rights and Responsibilities Respect: You and your time are important. Expect your counselor to keep appointments, and, when necessary, to reschedule well in advance; give you complete attention during sessions; and strive to provide the most effective counseling possible. In return, punctual attendance at appointments shows that you care about helping yourself. If you must reschedule, be responsible and considerate by calling the Counseling Office and giving advance notice. Progress & Participation: Your counselor will be concerned with helping you establish realistic goals and achieve effective results. Issues considered may be length and duration of appointments, interventions used, how progress will be evaluated, and deciding when to terminate counseling and/or refer to additional resources. You are encouraged to discuss these parts of the counseling process with your counselor. In addition, you will be assisted in learning about the full range of services available on campus and elsewhere in the community. You are encouraged to discuss with your counselor your feelings about the counseling and availability of other options. Confidentiality: Information you share during your use of resources in the Counseling Center will be held in the strictest reasonable expectations of confidentiality. If you are seeing a Counselor for Academic, Career, or Personal Counseling additional parameters apply to your confidentiality: information you share in counseling will be held confidential and will not be shared without your written permission. Exceptions to this would occur if, in the judgment of the counselor, such a disclosure were necessary to protect you or someone else from imminent danger, disruption of the academic environment, or if your records were subpoenaed by a Court of Law. Please sign and date below that you understand and accept these parameters. Student s Signature Date Counselor s Signature Date

14 South Georgia State College Counseling Office New Client Intake Form WARNING: If this is an emergency, call Campus Police (Douglas) or 911 immediately. First Name: * Middle Name: Last Name: * Date of birth (mm/dd/yyyy format)* Invalid date. Student ID: * Phone 1: OK to phone? Cell Phone: OK to phone? * OK to ? Address 1: Address 2: OK to contact at home?

15 South Georgia State College Counseling Office New Client Intake Form WARNING: If this is an emergency, call Campus Police (Douglas) or 911 immediately. Date of birth * Gender * Ethnicity Marital * Class * Major * GPA ** Are you a Full-Time Student? Yes No Are you currently on accademic probation? Yes No Residence * Current Medication(s) Reason for Visit Please explain the concern(s) you would like to address in counseling. * Client Demographics * Have you received previous counseling? Check if "YES" Have you received previous counseling from this center? Check if "YES" Other Center: When/ Who/ Where This center: When/ Who

16 South Georgia State College Counseling Office New Client Intake Form WARNING: If this is an emergency, call Campus Police (Douglas) or 911 immediately. Did you transfer from another campus/institution to this school? Yes No Client Information (SDS) Are you registered, with the office for disability services on this campus, as having a documented and diagnosed disability? Yes No If you selected, "Yes" for the previous question, please indicate which category of disability you are registered for (check all that apply): Attention Deficit/Hyperactivity Disorders Deaf or Hard of Hearing Learning Disorders Mobility Impairments Neurological Disorders Physical/health related Disorders Psychological Disorder/Condition Visual Impairments Other (please specify) Other disability: What kind of housing do you currently have? With whom do you live? (check all that apply) Other housing Alone Spouse, partner, or significant other Roommate(s) Children Parent(s) or guardian(s) Family other Other (please specify) Others living with Do you participate on an athletic team that competes with other colleges or universities? Yes No

17 Please indicate your level of involvement in organized extracurricular activities (e.g., sports, clubs, student government, etc.) What is the average number of hours you work per week during the school year (paid employment only)? Are you the first generation in your family to attend college? Yes No How would you describe your financial situation right now How would you describe your financial situation while growing up Think back over the last two weeks. How many times have you had: five or more drinks* in a row (for males) OR four or more drinks* in a row (for females)? (* A drink is a bottle of beer, a glass of wine, a wine cooler, a shot glass of liquor, or a mixed drink.) Attended counseling for mental health concerns Taken a prescribed medication for mental health concerns Been hospitalized for mental health concerns Felt the need to reduce your alcohol or drug use Others have expressed concern about your alcohol or drug use Received treatment for alcohol or drug use Purposely injured yourself *

18 without suicidal intent (e.g., cutting, hitting, burning, hair pulling, etc.) Seriously considered attempting suicide Made a suicide attempt Considered seriously injuring another person Intentionally caused serious injury to another person Had unwanted sexual contact(s) or experience(s) Experienced harassing, controlling, and/or abusive behavior from another person (e.g., friend, family member, partner, or authority figure) Have you experienced a traumatic event that caused you to feel intense fear, helplessness, or horror? If you selected, "Yes" for the previous question, please briefly describe the event(s): Please select the traumatic event(s) you have experienced, witnessed, or learned about: Childhood physical abuse Childhood sexual abuse Childhood emotional abuse Physical attack (e.g., mugged, beaten up, shot, stabbed, threatened with weapon) Sexual violence (rape or attempted rape, sexually assaulted, stalked, abused by intimate partner, etc.) Military combat or war zone experiences Kidnapped or taken hostage Serious accident, fire, or explosion (e.g., an industrial, farm, car, plane, or boating accident) Terrorist attack Near drowning Diagnosed with life threatening illness

19 Natural disaster (e.g., flood, quake, hurricane, etc.) Imprisonment or Torture Animal attack Witnessed the serious injury or unnatural death of a person due to an accident, war or disaster Unexpectedly witnessed a dead body or body part Learned that one's child or close loved one has a life threatening disease Learned about the violent personal assault, serious accident or serious injury of a close family member or friend Learned about the sudden unexpected death of a very close family member or friend Other (please specify)

20 South Georgia State College Counseling Office New Client Intake Form WARNING: If this is an emergency, call Campus Police (Douglas) or 911 immediately. CCAPS 62 (2009) INSTRUCTIONS: The following statements describe thoughts, feelings, and experiences that people may have. Please indicate how well each statement describes you, during the past two weeks, from 'not at all like me' (0) to 'extremely like me' (4), by marking the correct number. Read each statement carefully, select only one answer per statement, and please do not skip any questions. Not at all like me Extremely like me 1. I get sad or angry when I think of my family 2. I am shy around others 3. There are many things I am afraid of 4. My heart races for no good reason 5. I feel out of control when I eat 6. I enjoy my classes 7. I feel that my family loves me 8. I feel disconnected from myself 9. I don't enjoy being around people as much as I used to 10. I feel isolated and alone 11. My family gets on my nerves 12. I lose touch with reality 13. I think about food more than I would like to 14. I am anxious that I might have a panic attack while in public 15. I feel confident that I can succeed academically 16. I become anxious when I have to speak in front of audiences 17. I have sleep difficulties 18. My thoughts are racing 19. I am satisfied with my body shape 20. I feel worthless

Counseling Center Policies and Procedures

Counseling Center Policies and Procedures Counseling Center Policies and Procedures Consultation Services The Counseling Center provides students, staff, faculty, and parents with consultation on situations where input from mental health professionals

More information

UWM Counseling and Consultation Services Intake Form

UWM Counseling and Consultation Services Intake Form UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes

More information

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services

More information

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone

PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced

More information

Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648

Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Problems in love and work, as well as troubling symptoms like depression and anxiety, often lead people to seek therapy.

More information

James A. Purvis, Ph.D. Psychotherapy Services Agreement

James A. Purvis, Ph.D. Psychotherapy Services Agreement James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist

More information

Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No

Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No : Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:

More information

WHAT IS PTSD? A HANDOUT FROM THE NATIONAL CENTER FOR PTSD BY JESSICA HAMBLEN, PHD

WHAT IS PTSD? A HANDOUT FROM THE NATIONAL CENTER FOR PTSD BY JESSICA HAMBLEN, PHD WHAT IS PTSD? A HANDOUT FROM THE NATIONAL CENTER FOR PTSD BY JESSICA HAMBLEN, PHD Posttraumatic Stress Disorder (PTSD) is an anxiety disorder that can occur following the experience or witnessing of a

More information

Ann Dunnewold, Ph.D., 2012

Ann Dunnewold, Ph.D., 2012 1 Ann Dunnewold, Ph.D. 8140 Walnut Hill Lane, Suite 100 Dallas, TX 75231 (214) 343-1353 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important

More information

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code

ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from

More information

Technical Assistance Document 5

Technical Assistance Document 5 Technical Assistance Document 5 Information Sharing with Family Members of Adult Behavioral Health Recipients Developed by the Arizona Department of Health Services Division of Behavioral Health Services

More information

Associates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909

Associates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909 Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:

More information

Garland s Christian Counseling Center

Garland s Christian Counseling Center Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave

More information

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT The Bethesda Group Psychological Services, LLC Old Georgetown Office Park 7988 Old Georgetown Road, 8A Bethesda, Maryland 20814 Phone 301.718.4544 Fax 301.718.4545 info@thebethesdagroup.com PSYCHOTHERAPIST-PATIENT

More information

Marci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES

Marci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES The mission of the counselors at Synchronicity Counseling is to offer a holistic, nonjudgmental approach to therapy with an understanding that all human

More information

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER***** SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDER UNIT Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth,

More information

ADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No

ADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:

More information

Arrive 15 minutes before your scheduled appointment time.

Arrive 15 minutes before your scheduled appointment time. Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist

More information

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078

8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078 Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd

More information

University of Central Arkansas Counseling Center Student Health Center Suite 327 Conway, AR 72035 (501) 450-3138

University of Central Arkansas Counseling Center Student Health Center Suite 327 Conway, AR 72035 (501) 450-3138 Page1 University of Central Arkansas Counseling Center Student Health Center Suite 327 Conway, AR 72035 (501) 450-3138 UCA Counseling Center Client Information Eligibility: Counseling services of the Center

More information

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER***** SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDERS Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth, Texas

More information

Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889

Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document

More information

Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT

Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT PROFESSIONAL SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

PSYCHOTHERAPY CONTRACT

PSYCHOTHERAPY CONTRACT Aaron J. Dodini, Ph.D. Licensed Clinical Psychologist Licensed Marriage & Family Therapist PSYCHOTHERAPY CONTRACT Welcome to my practice. This document contains important information about my professional

More information

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM

GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM GONZABA MEDICAL GROUP PATIENT REGISTRATION FORM DATE: CHART#: GUARANTOR INFORMATION LAST NAME: FIRST NAME: MI: ADDRESS: HOME PHONE: ADDRESS: CITY/STATE: ZIP CODE: **************************************************************************************

More information

ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET

ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET COLLABORATIVE DIVORCE ENGAGEMENT AGREEMENT DIVORCE COACH This document contains important

More information

Deborah Issokson, Psy.D.

Deborah Issokson, Psy.D. Deborah Issokson, Psy.D. Licensed Psychologist HEALTHCARE PRIVACY AND SECURITY POLICIES PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important

More information

Marian R. Zimmerman, Ph.D.

Marian R. Zimmerman, Ph.D. Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date

More information

Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110

Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110 Riegler Shienvold & Associates (717) 540-1313 2151 Linglestown Road, Suite 200 Harrisburg, PA 17110 PROVIDER-PATIENT SERVICES AGREEMENT Welcome to Riegler Shienvold & Associates (RSA). This document (the

More information

Addiction Treatment Strategies

Addiction Treatment Strategies Patient Registration Legal Name First Middle Last Birth Date Address Street City State Zip Phone(s) Home Cell Work Is it ok to contact your cell? Yes No SSN Email (Used for appointment reminder) Known

More information

Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677

Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:

More information

Warner Family Counseling

Warner Family Counseling Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact

More information

Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional

More information

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

Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no 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 75182 www.nancythomascounseling.com Office: (972) 698-8478

More information

RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12)

RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043 1 PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) Welcome to my practice. This agreement contains important information

More information

Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030

Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030 Anna M. Trad, Ph.D., 1244 Clairmont Road, Suite 204 Decatur, GA 30030 PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about

More information

TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401

TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Minor Consent for Treatment and Service Agreement Welcome to Tidelands Counseling!

More information

PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT

PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary

More information

David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457

David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457 David Shanley PsyD, LLC 1776 S. Jackson St., Suite 204 Denver, CO 80210 Psychologist Candidate #00013457 DISCLOSURE INFORMATION & CONTRACT FOR PSCYHOLOGICAL SERVICES DATE: CLIENT NAME: BIRTHDATE: ADDRESS:

More information

Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.

Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling. Counseling Associates of Southern Illinois 1669 Windham Way, Suite B O Fallon, Illinois 62269 P: 618-622-2579 F: 618-624-8506 www.casicounseling.org I. Initial Client Information Date: Social Security

More information

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age: Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name

More information

Declaration of Practices and Procedures

Declaration of Practices and Procedures LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased

More information

Counseling Intake Form (Each person attending therapy should complete a form)

Counseling Intake Form (Each person attending therapy should complete a form) Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay

More information

Domestic Violence: Can the Legal System Help Protect Me?

Domestic Violence: Can the Legal System Help Protect Me? Domestic Violence: Can the Legal System Help Protect Me? What is domestic violence? Domestic violence is a pattern of physically and/or emotionally abusive behavior used to control another person with

More information

Post Traumatic Stress Disorder and Substance Abuse. Impacts ALL LEVELS of Leadership

Post Traumatic Stress Disorder and Substance Abuse. Impacts ALL LEVELS of Leadership Post Traumatic Stress Disorder and Substance Abuse Impacts ALL LEVELS of Leadership What IS Post Traumatic Stress Disorder (PTSD) PTSD is an illness which sometimes occurs after a traumatic event such

More information

Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip

Employed Full Time Student Part time student Patient s School Name / Employer School/Employer Address City State Zip PATIENT INFORMATION DATE: Patient s Name Last First Middle Initial Patient s Address City State Zip Patient s Birth Date / / Male Female Age SS# Single Married Other May we call/leave message for appt.

More information

Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036

Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 PSYCHOLOGIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement)

More information

PATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome!

PATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome! Jeremy Frank, PhD CADC Licensed Psychologist and Certified Alcohol and Drug Counselor Presidential City Madison Building 2 Bala Plaza, Suite Plaza 13 (Pl-13) Bala Cynwyd, Pennsylvania 19004 215-356-8061

More information

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center

Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Family Willows Co-Occurring Substance Abuse and Trauma Treatment Center Intensive Outpatient Program Participant Handbook Table Of Contents: Welcome..... Page 1 Introduction. Page 1 Staff Page 1 Informed

More information

New Perspective Counseling Services Child/Teen Intake Form

New Perspective Counseling Services Child/Teen Intake Form Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.

More information

Section A Victim/Applicant Information (A separate application must be completed for each victim.)

Section A Victim/Applicant Information (A separate application must be completed for each victim.) Application For Crime Victim Compensation Claim No. Arkansas Crime Victims Reparations Board 323 Center Street, Suite 200 Little Rock, Arkansas 72201 Office of the (501) 682-1020 or 1-800-448-3014 This

More information

AGAPE. Therapist Client Services Agreement

AGAPE. Therapist Client Services Agreement Revised 7/1/08 AGAPE Therapist Client Services Agreement AGAPE is a faith-based organization guided by Christian values. As part of its overall mission, AGAPE offers professional counseling and psychological

More information

PROFESSIONAL DISCLOSURE STATEMENT Information and Consent

PROFESSIONAL DISCLOSURE STATEMENT Information and Consent Molly Casebere, M.S., LPC, NCC Licensed Professional Counselor, North Carolina (License # 8518) Nationally Certified Counselor (Certification # 239857) PROFESSIONAL DISCLOSURE STATEMENT Information and

More information

Nichol A. Moses, Psy.D., NCSP

Nichol A. Moses, Psy.D., NCSP PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to

More information

JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT This document contains important information about my professional and business policies. It also

More information

Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, 80920. Denver Office 837 Sherman St. Denver, CO 80203

Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, 80920. Denver Office 837 Sherman St. Denver, CO 80203 Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, 80920 Denver Office 837 Sherman St. Denver, CO 80203 Welcome to my practice. I am honored that you are giving me the opportunity

More information

OUTPATIENT SERVICES CONTRACT

OUTPATIENT SERVICES CONTRACT OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone #

PATIENT INFORMATION. Patients Last Name First MI. SSN: DOB Age Sex: M F. Address. City State Zip Code. Home Phone # Alt. Phone # Boguslaw Gluszak, MD Date: PATIENT INFORMATION Patients Last Name First MI SSN: DOB Age Sex: M F Address City State Zip Code Home Phone # Alt. Phone # Parents/Guardians: N/A Name of Primary Insurance:

More information

GENESIS COUNSELING GROUP, S.C.

GENESIS COUNSELING GROUP, S.C. PSYCHOLOGY SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions

More information

Mosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION

Mosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION NEW CLIENT INFORMATION (Please Print) / / Client Name M/ F of Birth Address City/State Zip Home ( ) Work ( ) Cell ( ) Email Address: (Circle One) Minor Single Married Divorced Separated Widow Living Together

More information

COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT

COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT Jill Squyres, Ph.D. PO Box 2125 Eagle, CO 81631 drjsquyres@mac.com 970.306.69.86 (ph) 866.512.0078 (fax) COLORADO PSYCHOTHERAPY DISCLOSURE STATEMENT AND PSYCHOLOGICAL SERVICES AGREEMENT This services agreement

More information

James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc.

James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name

More information

PATIENT DEMOGRAPHIC INFORMATION FORM

PATIENT DEMOGRAPHIC INFORMATION FORM If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use

More information

Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606

Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document

More information

TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401

TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Adult Consent for Treatment and Service Agreement Welcome to Tidelands Counseling! Tidelands

More information

Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT

Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important

More information

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME

The McGregor Clinic Inc. Patient Registration/Demographic Form. Patient Enrollment PLEASE USE LEGAL NAME The McGregor Clinic Inc. Patient Registration/Demographic Form Patient Enrollment PLEASE USE LEGAL NAME First Name: MI: Last Name: of Birth: Sex: SS#: Marital Status: Single Married Separated Divorced

More information

602%548%8508!(Main!Office)! 623%670%2927!(Direct!Line)! 17505!N.!79 th!avenue,!suite!410! Glendale,!AZ!85308!

602%548%8508!(Main!Office)! 623%670%2927!(Direct!Line)! 17505!N.!79 th!avenue,!suite!410! Glendale,!AZ!85308! 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

More information

TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452

TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 Dorothy B. Brown, Ph.D. Anne Davidge, Ph.D. Dennis J. Rog, Ed.D. Licensed

More information

Nj Victims of Crime Compensation Office

Nj Victims of Crime Compensation Office Nj Victims of Crime Compensation Office Claim Information and Application Instructions New Jersey has a Crime Victim s Compensation Fund to help with costs related to injuries received in a violent crime.

More information

Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328

Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.

More information

What is DOMESTIC VIOLENCE?

What is DOMESTIC VIOLENCE? What is DOMESTIC VIOLENCE? Domestic violence is a pattern of control used by one person to exert power over another. Verbal abuse, threats, physical, and sexual abuse are the methods used to maintain power

More information

Jane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301

Jane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301 Patient Information (PLEASE PRINT) Patient Name: _ Today s Date: Patient s SSN: - - DOB: / / Age: Sex: Marital Status (circle): Single Married Separated Divorced Other: Home Address: Email: OK to leave

More information

OFFICE POLICIES AND SERVICE AGREEMENT

OFFICE POLICIES AND SERVICE AGREEMENT Thomas Cicciarelli, Psy.D. PSY17298 350 Parnassus Avenue, Suite 601. San Francisco, CA 94117. 415-767-5199 OFFICE POLICIES AND SERVICE AGREEMENT Introduction Welcome to my practice. This document contains

More information

Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355

Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355 Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355 CLIENT INFORMATION AND CONSENT Welcome to my practice. This document

More information

OK to leave Messages?

OK to leave Messages? Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date

More information

COURTNEE A. PELTON, PSY.D.

COURTNEE A. PELTON, PSY.D. 1 COURTNEE A. PELTON, PSY.D. 703-343-0849 CPELTON.PSYCH@GMAIL.COM Outpatient Services Contract Welcome to my practice. This agreement contains important information about my professional services and office

More information

Sincerely, the staff at NVCC.

Sincerely, the staff at NVCC. Thank you for choosing North Valley Christian Counseling. We look forward to working with you. Please take a few minutes to fill out the following forms. We will also take a few moments at the beginning

More information

INTAKE SERVICES HIGHER LEVEL OF CARE REFERRAL

INTAKE SERVICES HIGHER LEVEL OF CARE REFERRAL INTAKE SERVICES HIGHER LEVEL OF CARE REFERRAL DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES 1825 Faulkland Road Wilmington, DE 19805 (302)

More information

Peaceful Path Counseling, LLC Amy Kay, LPC

Peaceful Path Counseling, LLC Amy Kay, LPC Revision VII, Effective January 15, 2015 Please Keep This for Your Records INTRODUCTION Welcome to my counseling practice. The decision to pursue counseling is an important one, often filled with questions.

More information

I. Each evaluator will have experience in diagnosing and treating the disease of chemical dependence.

I. Each evaluator will have experience in diagnosing and treating the disease of chemical dependence. PREVENTION/INTERVENTION CENTER COBB COUNTY PUBLIC SCHOOL SAFE AND DRUG FREE PROGRAM www.cobbk12.org/~preventionintervention CONTRACT FOR SERVICE PROVIDERS As a member of the Cobb County Schools Coalition

More information

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515

IRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515 : / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell

More information

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.

WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance. Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work

More information

Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835

Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835 Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835 Professional Policies and Consent to Treatment Welcome to my practice. I appreciate your giving me the

More information

Informed Consent and Clinical Policies

Informed Consent and Clinical Policies THRIVE Center for ADHD and Comprehensive Mental Health Informed Consent and Clinical Policies Welcome to THRIVE. This document contains important information about our professional services and business

More information

Mendel Psychological Associates

Mendel Psychological Associates PSYCHOLOGIST- PATIENT SERVICES AGREEMENT This document is an agreement between therapist: and client:. Welcome to our practice. This document (the Agreement) contains important information about professional

More information

SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)

SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial) Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples

More information

Michael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation of a Minor Child. who was born on and who resides at

Michael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation of a Minor Child. who was born on and who resides at Michael S. McLane, Psy.D. Licensed Psychologist 12830 Hillcrest Road Suite D233 Dallas, TX 75230 Ph: (972) 620-1225 Fax: (972) 620-4393 Informed Consent to Treatment / Evaluation of a Minor Child I am

More information

CLIENT QUESTIONNAIRE

CLIENT QUESTIONNAIRE Leland E. McHatton, MFT Marriage Family Therapist 1430 East Avenue, Suite 4C 530.566.1212 Chico, California 95926 CLIENT QUESTIONNAIRE Client s Name: Spouse s or Parent s Name: Date of Birth: Date of Birth:

More information

VICTIM COMPENSATION APPLICATION

VICTIM COMPENSATION APPLICATION OFFICE OF THE ATTORNEY GENERAL Crime Prevention & Victim Services Crime Victim Compensation Division Post Office Box 220 Jackson, Mississippi 39205-0220 1-800-829-6766 or 601-359-6766 601-576-4445 (FAX)

More information

LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062

LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 PHONE: 847.497.8378 LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062 Intake Form Date of Intake: Caller: DRLEIGHWEISZ.COM Referral Source: May I thank referral

More information

COUPLES THERAPY INTAKE FORM Please complete this form individually

COUPLES THERAPY INTAKE FORM Please complete this form individually COUPLES THERAPY INTAKE FORM Please complete this form individually Date file opened: Chart #: First name: Last name: Age: Birth day: Month: Year: Ethnicity: Religion: Marital Status: Sex/gender: Number

More information

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187

Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document

More information

Informed Consent for Counselling at the University of Lethbridge 1

Informed Consent for Counselling at the University of Lethbridge 1 Informed Consent for Counselling at the University of Lethbridge 1 Purpose: For you to understand the process and nature of counselling as well as the associated risks and benefits, in order for you to

More information

REFERRAL INFORMATION CHILD, YOUTH AND FAMILY PROGRAM

REFERRAL INFORMATION CHILD, YOUTH AND FAMILY PROGRAM Please Note the following information: WE DO NOT OFFER EMERGENCY OR CRISIS SERVICE Please print clearly and ensure contact information is correct. Complete all forms. We will contact the family to set

More information

New Venture Christian Fellowship Therapy Introduction to Individual Counseling

New Venture Christian Fellowship Therapy Introduction to Individual Counseling New Venture Christian Fellowship Therapy Introduction to Individual Counseling Welcome to counseling. We look forward to meeting with you and getting started. People and their situations are often very

More information

MEDICAL RECORDS ACCESS GUIDE IOWA

MEDICAL RECORDS ACCESS GUIDE IOWA MEDICAL RECORDS ACCESS GUIDE IOWA Parsonage Vandenack Williams LLC Attorneys at Law Parsonage Vandenack Williams LLC 2008 For more information, contact info@pvwlaw.com TABLE OF CONTENTS Iowa...1 Patient

More information

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM NOTICE OF PRIVACY PRACTICES Effective Date: April 14, 2003 UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information