1 Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work How would you like to be contacted? Home Work Okay to leave a message? yes no *If client is a minor, name of parent or legal guardian Emergency Contact Name Phone Relationship to Client History Are you under a doctor s care? If yes, name of doctor Reason for doctor s care Are you taking any medication? If yes, what kind? Reason for medication Last medical exam Have you ever been hospitalized for a physical illness? If yes, describe? Have you ever been hospitalized for a mental illness? If yes, describe? Have you had counseling/therapy in the past? If yes, describe when, where, how long, what for: What do you hope to achieve with this therapy?
2 Stephanie McIntyre, M.A. Licensed Professional Counselor (512) counselwithstephanie.com Psychotherapy - Client Services Agreement The purpose of this document is to introduce you to the services, agreements, definitions and limitations of my professional practice. Should you decide to work with me, this document will provide you with information you may find helpful in optimizing your experience. It also includes information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client s rights with regard to the use and disclosure of your Protected Health Information (PHI), used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment, and health care operations. This Notice which will also be provided for you explains HIPAA in greater detail. The law requires that I obtain your signature verifying that I have provided you with this information at the end of this intake session. It is important that you review these documents before our next session. Any questions you may have will be addressed at that time. Introduction: In order to assist in making a decision to work with me, you may want to know some things about my professional history, experience and theoretical perspectives. I hold a Bachelor of Science degree in Industrial Psychology from Fairmont State University and a Master of Science degree in Industrial Relations from West Virginia University. I also hold a Master of Arts in counseling from St. Edward s University in Austin, Tx. I have lived in Austin since I was employed in the high-tech industry for over a decade. I have multiple hobbies and interests and am an active member in my church. I feel my personal experiences and education have qualified me to connect and empathize with my clients in order to help them examine and redefine multiple aspects of their lives within a therapeutic setting. My practice embraces an all-encompassing approach toward making changes in multiple areas of your life based on Albert Ellis s theory of Rational Emotive Behavior Therapy (REBT). REBT is an action-directed therapy in which emotional and behavioral problems are addressed through exploration of your beliefs. Ellis believed that if you change your thinking you can change your life. Based on his premise, I believe it is important to explore multiple areas of your life and the beliefs you act upon in order to discover opportunities where you can implement empowering changes. I don t want to just help you feel better.i want to help you change your life! My therapeutic style is didactic and motivational. I work closely with the client to facilitate exploration of various areas of the client's life. This collaborative effort leads to a customized approach to therapy based on the needs of each individual and involves a whole-life application which includes the mind, body and spirit. I believe it is important for the client to feel empowered, encouraged and educated during the counseling process.
3 The Process of Psychotherapy: Psychotherapy is difficult to define. It can be as variable and unique as the range of clientele seeking a psychotherapeutic experience. It can require a few sessions over a few weeks; over a number of months; and sometimes over several years to accomplish the change desired. It can assist in addressing a specific and limited issue; or it can be a life changing, redemptive, or even a life saving experience. Usually, in order for therapy to be effective, the individual, or couple, or family has to be motivated to address the issue or issues sufficiently to invest the time, energy, and resources necessary for real change to occur. The process can be uncomfortable, even painful when difficult issues are faced. However, when clients are willing to reflect upon the challenging aspects of their lives, examine the patterns, roles, and dynamics they discover, and take the risks real change requires, the results can not only be gratifying but transformative as well. Intake: The intake session is not really therapy. It is an opportunity to determine if the goals of the client and the expertise of the therapist are a match. I believe that the process of selecting a therapist is very important and should be made with care. I attempt to create an atmosphere wherein the client(s) can feel free to ask the questions needed to make that decision. I, too, need to be able to ask questions to determine if my expertise falls within the area of client concerns. Normally, the first few sessions are devoted to this exploratory process. Even though therapy begins after the first session, both you and I may decide that your needs may be better served by someone else. In this case, I will attempt to assist with a referral. There are also situations for which I may recommend adjunctive services; body work, group psychotherapy, medical or psychological evaluation, art therapy, to name a few. You are always free to pursue these additions and alternatives or not. Psychotherapy is a voluntary process which you have the right to discontinue at any time. It can be an important part of the therapeutic process to discuss when you believe that your needs have been met and you are ready to discontinue the process. Many times, clients discover they want to come back occasionally for a tune up or to address new circumstances in their lives. Once a client has successfully worked with me, they are always welcomed back to work on subsequent issues. Appointment scheduling: Appointments are usually 50 minutes in length. I attempt to start appointments on the hour. If an appointment begins a few minutes late, I will attempt to be sure the client receives a fifty minute session without encroaching on the next client s time. Normally sessions are weekly; however, dependent upon the need of the client, sessions can be scheduled more or less frequently. After initial assessments, many couples and families prefer sessions every two weeks. For some clients in the later stages of therapy, sessions can be scheduled once every month or six weeks. Cancellations: I require notice of cancellation 24 hours in advance. 24 hour notice is the standard notification period in the profession. A $40 late fee is required if notice is not received. Fees: My fee is $90 per 50-minutes and $135 for 90-minute sessions. When clients are unable to afford my regular fee, I may utilize a sliding scale to determine the hourly fee based on the client s household size and income level. I ask my clients to pay what they feel is appropriate for them within that fee scale. I want my clients to be able to afford their counseling sessions so
4 it is important for us to agree upon a fee that will be fair to the both of us. Report writing, inpatient services or any involvement in legal proceedings is billed at the higher rate because of the inherent complexity of these involvements. Longer sessions are prorated at the selected client fee. Phone sessions over 10 minutes are also prorated at the selected client fee. Payment: Payment is made by cash, check or credit card at the end of each session. Please bring exact change if you plan to pay with cash. Clients are expected to reimburse any returned check fees. Upon request, I will provide a receipt of services which may be used for reimbursement of fees by your insurance carrier or for your personal records. I can provide these receipts for each session, monthly, or yearly as per your request. Insurance: I am currently in the process of qualifying for several insurance boards. Until then, I can provide you with a receipt for counseling services that you may submit to your insurance company for possible reimbursement. Concerned about using your insurance? See my website Fees page to learn more about using your insurance: Telephone and After-Hours Procedures: My voic is private and no one else will have access to hear your messages. If you do leave a message, I will attempt to return your call as soon as possible. Messages left on weekends and holidays will be responded to when I return to the office. Telephone sessions and long-distance sessions may be held under certain circumstances. Telephone sessions will be billed at the client s agreed-upon per-session fee including any telephone conversation lasting more than 10 minutes. If you need immediate assistance and are unable to reach me, please contact your family physician, nearest emergency room or one of the following: 24-hour crisis hotline 472-HELP Shoal Creek Psychiatric Hospital Safeplace 277-SAFE General Emergency 911 Ethics: As a Licensed Professional Counselor, I abide by the professional standards of my profession. You can discuss those standards with me, or contact the Licensing Board of Licensed Professional Counselors through the Texas Health Department to obtain a copy of those standards. Records: As required by law, I keep a record of your sessions. HIPAA permits the keeping of two sets of records. One is your Clinical Record which may contain your goals for therapy, your diagnosis, treatment progress, social history, past treatment records received from other providers, reports, letters, Payment records, and insurance documentation. I also may keep a second set of Psychotherapy notes which are for my own use to assist me in providing you with the best service possible. It is my practice to keep minimal records containing only basic information pertinent to my understanding of the goals of your therapy. Insurance companies can receive a copy of your Clinical Record but cannot receive a copy of your Psychotherapy notes without a signed authorization from you.
5 Confidentiality: The law protects the privacy of communication between a licensed therapist and a client(s). In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements required by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities which include: 1. I may occasionally find it helpful to consult or communicate with other mental health professionals including my supervisor about a case. I always make every effort to protect the identity of my client(s). The other professionals are legally bound to keep the information confidential as well. 2. If a client seriously threatens to inflict imminent physical, mental, or emotional harm on him or herself or others, I may be obligated to seek hospitalization for that client, or to contact law enforcement officials, family members, or other interested parties to assist in providing protection. There are some situations where I am permitted or required to disclose information without either your consent or authorization. They are as follows: 1. If I have cause to believe that a child under 18 has been or may be abused or neglected (physical injury, substantial threat of harm, mental or emotional injury, any kind of sexual contact or conduct), or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the appropriate governmental agency. Once such a report is filed, additional information may be required. 2. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, I cannot provide any information without your or your legal representative's written authorization, or a court order. If you are contemplating litigation or are involved in litigation, it would be in your best interest to determine the likelihood of whether a court would order me to disclose information. 3. If you disclose information regarding a sexual involvement with a mental health professional who was involved in your care, I am required to report this to the appropriate state board. 4. If a government agency is requesting information for health oversight activities, I may be required to provide information to them. 5. If a patient files a complaint or lawsuit against me, I may disclose relevant information in order to defend myself. 6. If a patient files a workman's compensation claim, I am required, upon appropriate request to provide records pertaining to treatment or hospitalization for which compensation is being sought.
6 If any of the above situations arise, I will make every effort to discuss the situation with you prior to disclosure and will disclose only what is necessary. Confidentiality with Minors, Couples and Groups: 1. When I work with minors, I ask parents to respect the confidentiality of their child. Therapy is not possible without trust. The law gives parents and guardians the right to see records if the child is under 18. I will ask the child's permission to discuss his/her therapy with parents or guardians in response to parent's questions as the child and I feel would be helpful. Even then I will only offer general information unless the child and I agree otherwise. Exceptions would include imminent harm or child abuse or neglect as indicated above. 2. Couples and family therapy can be very complex. Confidentiality issues will be discussed as needed. 3. Members of psychotherapy groups are required to maintain confidentiality regarding the identity of group members and the personal information shared during sessions.
7 Stephanie McIntyre, M.A. Licensed Professional Counselor (512) counselwithstephanie.com Notice of Policies and Practices to Protect the Privacy of Your Health Information : HIPAA (Health Insurance Portability and Accountability Act This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations Requiring Your Advance Consent I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: PHI refers to information in your health record that could identify you. Treatment, Payment, and Health Care Operations: Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician, social worker, therapist, psychologist, or psychiatrist. Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. Use applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties. II. Uses and Disclosures Requiring Your Specific Written Authorization I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. Psychotherapy notes are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization, or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to consent the claim under the policy. III. Uses and Disclosures Requiring Neither Your Consent nor Authorization I may use or disclose PHI without your consent or authorization in the following circumstances:
8 Child Abuse: If I have cause to believe that a child has been, or may be abused, neglected, or sexually abused, I must by law make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law enforcement agency. Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Texas Department of Protective and Regulatory Services. Abuse by a Therapist: If I have cause to believe that you have been the victim of sexual exploitation by a mental health professional during the course of treatment, I will report this to the appropriate State Examining Board. Health Oversight: If a complaint is filed against a therapist with the appropriate overseeing State Board (The Texas State Board of Examiners of Psychologists, the Texas Board of Medical Examiners, the Texas State Board of Social Work Examiners, or the Texas State Board of Licensed Professional Counselors); they have the authority to subpoena confidential mental health information from the therapist relevant to that complaint. Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law. Therefore, I will not release information without written authorization from you or your personal or legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety: If I determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel. Worker's Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer's insurance carrier. IV. Your Rights Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send information to another address.) Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process. Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process. Right to Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
9 Right to a Paper Copy: You have the right to obtain a paper copy of this notice from me upon request, even if you have agreed to receive the notice electronically. V. My Duties I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you a revised copy at your next visit or by mail. VI. Complaints If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, please talk to me about these concerns. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.
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.
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Welcome to our practice! We are so happy you booked your first appointment. Enclosed you will find your new client paperwork and some important information about our office. You have two main things to
NOTICE OF PRIVACY PRACTICES FOR THE NORTH CENTRAL NURSING CLINICS This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. EFFECTIVE September 15, 2014 This Notice of
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
Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 email@example.com CLIENT INFORMATION AND CONSENT Welcome to my practice. This document contains important
Notice of Privacy Practices Human Resources Division Employees Benefits Section THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
HIPAA NOTICE OF PRIVACY PRACTICES Human Resources Department 16000 N. Civic Center Plaza Surprise, AZ 85374 Ph: 623-222-3532 // Fax: 623-222-3501 TTY: 623-222-1002 Purpose of This Notice This Notice describes
APPLETREE PEDIATRICS, PA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
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
HIPAA Notice of Privacy Practices Date of Last Revision: 09/20/2013 Effective Date: Immediately THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Uses and Disclosures
Notice of Privacy Practices Pueblo Radiology Medical Group, Inc. Pueblo Radiology Associates, Inc. Central Coast Radiology Associates, Inc. Santa Barbara Women s Imaging Center Effective Date: September
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