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

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1 Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA An important part of the helping relationship is understanding the expectations of the relationship. Please read the following information and sign to acknowledge that you have read and understand the consent. Please keep one copy for yourself. Thank you. Fees: Our office sessions are scheduled for 50 minutes and are billed at $ Specific advice and education regarding your child s needs are provided in a collaborative approach. These meetings are not considered a therapy session. Sliding scale is available as needed. Telephone Calls: Brief phone calls and initial consultation for service calls are not charged. If our conversation is longer than 15 minutes and is clinical in nature, the phone call will be charged as follows: minutes $35.00 and 30 minutes or longer will be $ Emergencies: I can be reached for clinical emergencies at (404) , and I will return your phone call within 24 hours. If you have an emergency and cannot wait 24 hours for a return call, please call 911. Cancellations: I understand that sometimes it is not possible to make a scheduled appointment. Please do all you can to give me at least 24 hours notice if you need to cancel an appointment. If not, a fee may be charged of $ Payment: It is expected that you pay for your services at the time of the visit. In addition to checks and cash, all major credit cards are accepted: Visa, MasterCard, Discover, and American Express. Insurance: I do not file insurance claims. However, my services may be covered by insurance. Since coverage varies widely from policy to policy, I cannot guarantee that my services will be reimbursed by your policy. I request that you please file directly for reimbursement with your insurance carrier. I can provide you with the bill for services which you will attach to your insurance claim. Billing: It is my pleasure to work with you. However, if you have an outstanding balance at the end of the month, you will receive a monthly statement of your account, which is payable upon receipt. Should your account become delinquent, the total amount due will accumulate at a rate of 1.5% per month until paid in full. Should your account have to be collected through an attorney, you will be responsible for all reasonable attorneys fees and the cost of all collections. Thank you very much for the opportunity to work with you. Karen Kallis, M.Ed., LAPC, NCC Signature Date / / 1

2 Consent for Counseling Please read this information carefully and discuss any questions you may have with me. Please keep one copy for yourself and sign one to acknowledge you have read and understand this consent. Thank you. Confidentiality: Our communication will be held in confidence and will not be revealed to outside agencies without your written consent. Divulgence of communications will not be permitted without your consent unless specifically required by law (for example: child abuse, elder abuse, imminent threat of danger to yourself or others, court order, etc.). Information released to insurance companies for reimbursement purpose is released only on authorization from you. However, if you waive confidentiality for your insurance company, they may request that your entire record for counseling be released. Please be sure that you are clear about what information your insurance company is requesting before you waive confidentiality. May I communicate with your referring professional for feedback? Yes No Referring professional Phone ( ) - Are there any other professionals or agencies that you wish for me to contact? Yes No Please list them below with contact information: Phone ( ) - Phone ( ) - Phone ( ) - Factors in Therapy: It is my pleasure to work with you. However, the success of therapy is affected by many things: severity of the problem, match between therapist and patient, motivation of the patient, and many other factors may also affect the length of the therapy. Please feel free to discuss your feelings with me about your progress and the course of therapy. Typically, the decision to terminate therapy is made by mutual consent of the therapist and patient. In the event that you decide to discontinue counseling without notifying me, it is my policy to assume that the counseling relationship terminated 30 days from your last visit. Thank you for the opportunity to work together. I acknowledge that I have read the business policy and consent for counseling. Please print your name clearly Signature Date / / Social Security Number - - 2

3 Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA Adult Information Form Client s name: Today s Date: Age: Date of Birth: Marital Status: Address: Name of Employer (if applicable): Occupation (if applicable): Education level: Home Phone: Ok to leave Voice Mail: Yes or No Cell Phone: Ok to leave Voice Mail: Yes or No Work Phone: Ok to leave Voice Mail: Yes or No Ok to contact via Yes or No Please indicate any restrictions to contact information: Referred by: May I have your permission to thank the person that referred you? Yes No Person to notify in case of emergency and relationship to client: Contact information for emergency contact: We will only contact this person if we believe it is an emergency. Please provide your signature to indicate that we may do so: Client Signature: Date: 3

4 Please describe the problems you are having that prompted you to seek therapy: What are your goals for therapy? Do you have any history of significant medical problems or illnesses? Yes No If yes, please describe below: Have you had any medical or psychiatric hospitalizations? Yes No If yes, please describe below: Have you ever talked with a psychiatrist, psychologist, or other mental health professional? Yes No If yes, When? With Whom? For how long? Was it helpful? Have you been given a diagnosis with respect to psychological or developmental concerns? Yes No If yes, please describe below: 4

5 Please check all that apply Problems Now Past Comments Anxiety Depression Mood Changes Anger or Temper Panic Fears Irritability Concentration Loss of Memory Excessive Worry History of Child Abuse History of Sexual Abuse History of Physical Abuse Feeling Manic Domestic Violence Thoughts of Hurting Someone Else Drug Problems Alcohol Problems Thoughts of Hurting Self Hurting Self Attempted Suicide Nightmares Hyperactivity Finances Legal Problems Sexual Concerns 5

6 Problems Now Past Comments Trusting Others Communicating with Others Often Make Careless Mistakes Parents People in General Marriage/Partnership Friend(s) Co-Worker(s) Employer Speak Without Thinking Fidget Frequently Distracted by Noises Waiting Your Turn Completing Tasks Sweating Heart Palpitations Muscle Tension Pain in joints Allergies Frequent Vomiting Sleeping Too Little Eating Problems Getting to Sleep Paying Attention Severe Weight Gain Nausea Abdominal Distress 6

7 Problems Now Past Comments Fainting Dizziness Diarrhea Shortness of Breath Chest Pain Lump in the Throat Headaches Caffeine Sleeping Too Much Waking Too Early Easily Severe Weight Loss Blackouts Head Injury Chills or Hot Flashes 7

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