Disclosure Statement & Policies
|
|
- Barry Morgan
- 5 years ago
- Views:
Transcription
1 - Medicaid Disclosure Statement & Policies Caitlin Kozicki LLC 7220 W. Jefferson Ave., Ste 218 Lakewood, CO S. Curtice St. Littleton, CO This disclosure statement of practice and office policies will help you clearly understand your rights and responsibilities as a client and mine. It should be read carefully. Your signature on the last page of this document represents an agreement between us. My Education and Credentials: Bachelor of Arts in Psychology: Montana State University Required 120 hours of credit hours of coursework. Master of Counseling Psychology: Pacific University Required 63 credit hours of coursework and 700 hours of clinical experience. Licensed Professional Counselor (LPC) Required a Master s Degree in counseling psychology, 2,000 hours of clinical experience, a passing score on the National Counselor Exam, and 100 hours of clinical supervision. Certified Addiction Counselor III (CAC III) Required a Bachelor s Degree in behavioral health, complete additional required training hours, and 2,000 hours of supervised experience. Certified Employee Assistance Professional (CEAP) Required a clinical Master s Degree, 1,000 hours of working in an Employee Assistance Program (EAP) setting, 12 hours of advisement, 20 professional development hours, and a passing score on the CEAP exam. National Certified Counselor (NCC) Required a Master s Degree in counseling psychology and a passing score on the National Counselor Exam. Colorado Certified Prevention Specialist (CCPS) II Required a passing score on the IC&RC examination (except during the grandfathering period prior to October 2013), 120 hours of prevention specific education (24 hours of this must be specific to alcohol, tobacco, and other drugs), 6 hours of education specific to prevention ethics, 31 hours must be Substance Abuse Prevention Skills Training (SAPST) (except during the grandfathering period prior to October 2013), 2,000 hours of prevention experience, and 120 hours of supervision specific to the prevention domains. My Methods: I use a combination of different therapeutic techniques, including cognitive-behavioral, solution focused, EMDR (Eye Movement Desensitization and Reprocessing) therapy, and motivation interviewing techniques. There may be risks and benefits involved in all of these types of therapy. If you ever have a questions or concern about my methods, please ask me about them. Regulatory Requirements: The practice of licensed or registered persons in the fields of psychotherapy, social work, counseling, nursing, dentistry, and pharmacy in Colorado is regulated by the Department of Regulatory Agencies. They can be reached at 1560 Broadway, Suite #1350, Denver, Colorado 80202, (303) , or via their website at Page 1 of 6
2 The regulatory requirements applicable to mental health professionals: A registered psychotherapist is a psychotherapist listed in the State's database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. Certified Addiction Counselor I (CAC I) must be a high school graduate, complete required training hours and 1,000 hours of supervised experience. Certified Addiction Counselor II (CAC II) must complete additional required training hours and 2,000 hours of supervised experience. Certified Addiction Counselor III (CAC III) must have a bachelor s degree in behavioral health, complete additional required training hours and 2,000 hours of supervised experience. Licensed Addiction Counselor must have a clinical master s degree and meet the CAC III requirements. Licensed Social Worker must hold a master s degree in social work. Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master s degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. Your rights: You have the right to: Terminate therapy at any time. Seek a second opinion from another therapist. Receive information about my methods of therapy, the techniques I use, the duration of therapy, and my fee structure. Please ask if you would like to receive this information. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental Health Section. Confidentiality: Generally speaking, the information provided by and to the client during appointments is legally confidential and cannot be released without the client s consent. There are exceptions to this confidentiality, some of which are listed in section of the Colorado Revised Statutes, and the HIPAA Notice of Privacy Rights you were provided as well as other exceptions in Colorado and Federal law. Some limits of confidentiality are: Threat of harm to self or others, including grave disability Known or suspected child abuse Known or suspected elder abuse Court order, or other mandate of State and/or Federal Law Written consent from the client If a legal exception arises, if feasible, you will be informed accordingly. The Mental Health Practice Act (CRS , et seq.) is available at: Updated: 2/25/2015 Page 2 of 6
3 Services provided & referrals: Services included will be an assessment, counseling, and referrals to community services as needed. If it is determined following the assessment that the presenting issue(s) require services beyond my scope as a provider, you will be provided referrals either through your insurance carrier or to a provider in the community that can provide more specialized therapy. This will be discussed with you. Consultation: The competent and ethical practice of psychotherapy dictates that I participate in regular case consultation with other licensed professionals. These other professionals are also legally bound to keep any information discussed confidential. Should I obtain consultation regarding aspects of your treatment, I will omit identifying information (including your name, place of employment, etc.) so that your confidentiality will be preserved to the best of my ability. Your signature on this policy serves as consent that I may obtain consultation regarding your treatment (on an anonymous basis) without a specific release to do so. HIPAA: You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. If I transmit information about you electronically (e.g., ing or faxing information), special safeguards will be utilized to ensure confidentiality. s: Please note that the confidentiality of communication is not secure, and therefore I try to avoid it as much as possible when communicating with you about your treatment. If you me about something related to treatment, you are consenting to use with full knowledge that it is not a secure medium. s can be used for asking simple questions, asking about rescheduling an appointment, a quick update, etc. may also be used for appointment reminders and self-help information. Health Care Coordination: It is important to make sure that the problems you present are not related to a physical health issue. Since I am not a medical provider, I cannot determine if you have a physical condition that might be related to your mental health and reason for accessing services with me. Therefore, if you have not had a physical examination in the past 12 months, you should get one as soon as possible. It would be best to tell your medical provider that you will be working with me so that we might begin to coordinate your health care. With your written authorization, I may obtain your medical records so I have a better understanding of your overall health. Appointments: We will schedule our appointments via phone, , or in person. You may call me at to schedule an appointment. My office hours are typically Tuesday through Saturday and I will make every effort to honor and accommodate your appointment preference. We will start and end on time. I cannot accommodate making up for lost appointment time unless it is due to my error or tardiness. I understand that in marriage and family counseling, Caitlin Kozicki holds a NO SECRETS policy. All members of the couple or family system are treated equally and secrets are not kept by the psychotherapist that requires differential or discriminatory treatment of family members. I understand that any information shared in any individual therapy MUST be also shared in couple or family therapy to insure this NO SECRETS policy. Signing this disclosure statement affirms permission for my psychotherapist to share this confidential information as deemed necessary for treatment. Updated: 2/25/2015 Page 3 of 6
4 Missed Appointment/Late Cancellation: Cancellations/rescheduling must be arranged at least 24 hours before the appointment by phone/text ( ). If an appointment is missed or cancelled/rescheduled within 24 hours of the appointment, we will discuss barriers and strategies to help you attend your scheduled appointments. If there are multiple missed or late cancelled appointments we will discuss referrals to other providers or discharge from services. In case of inclement weather, a challenge with transportation, or any reason you are unable to reach my office for an inperson appointment, you may have the option to attend the appointment via phone. This needs to be coordinated prior to the start time of your scheduled appointment. Otherwise the appointment will be cancelled/rescheduled. Standing Appointments: If there is a standing appointment time made on a weekly, biweekly, or monthly basis the client agrees that though this appointment is not created the session before it is still the client s responsibility to cancel the appointment within 24 hours or the above charges will apply. Appointment Length: Counseling appointments are either 50 or 60 minutes in length. This will be discussed and determined with you. Record Keeping: I will keep brief records, noting that we have met, what interventions were used in appointment, and the topics discussed. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make copy of your file available to any other health care provider at your written request. I maintain your records on a secure hard drive and/or in a locked filing cabinet that cannot be accessed by anyone else. Limitation of Services: I do not offer 24-hour care. If you need after-hours care, I will assist you in finding the proper resources. If you are experiencing a mental health emergency, call 911 immediately. You can also contact the National Suicide Prevention Lifeline at TALK (8255), Rocky Mountain Crisis Partners at , or Postpartum Support International support helpline at PPD (4773). Counseling relationship and professional boundaries: I will not, at any time, have a social relationship with you outside of my office, whether we have ended our therapy relationship or not. I will not accept social or family invitations from you, and I will not offer them to you. This is not for a lack of interest or care. To ensure your confidentiality as a client, if I were to see you in public at any time, I will not initiate any contact or familiarity with you beyond basic pleasantries. If you choose to initiate a visible or audible greeting, I will reciprocate but will not attempt further communication unless you request it. Risks & Benefits: During the course of therapy, you might notice changes in your symptoms, problems, and/or functioning. Since we will be exploring challenging territory for you personally, in your relationships and/or life, you might experience greater difficulty throughout our work. However, as you work through your areas of difficulty and build upon your strengths, it is likely that you will see improvements throughout our work and in your future. Please be advised that counselors cannot guarantee successful therapy outcomes. Updated: 2/25/2015 Page 4 of 6
5 Ending Counseling: You normally will be the one who decides counseling will end, with a few exceptions: If I am not, in my judgment, able to help you because of the kind of problem you have or because my training and skills are not appropriate, I will inform you of this fact and refer you to another therapist who may meet your needs. If you are violent or threatening toward myself, the office, or my family, I reserve the right to terminate you unilaterally and immediately from treatment. If you have multiple missed or late cancelled appointments despite discussing barriers and strategies to attend scheduled appointments. If I end counseling with you, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy. Updated: 2/25/2015 Page 5 of 6
6 Disclosure Statement & Policies Caitlin Kozicki LLC 7220 W. Jefferson Ave., Ste 218 Lakewood, CO S. Curtice St. Littleton, CO Your signature indicates an informed consent to counseling and agreement to the following: I have read the Disclosure Statement & Policies and understand it. I have had the opportunity to ask Caitlin Kozicki, MA, NCC, LPC, CAC III, CEAP, CPS II questions and to be provided further explanation pertaining to the Disclosure Statement & Policies. I agree to follow the terms, policies, and responsibilities in the Disclosure Statement & Policies. I understand that appointments are between minutes unless otherwise agreed and documented. I have read the preceding information, it has also been provided verbally, and I understand my rights as a client or as the client s responsible party. Client signature: Date: Client Name (printed): Counselor signature: Counselor Name (printed): Caitlin Kozicki, MA, NCC, LPC, CAC III, CEAP, CPS II Date: Updated: 2/25/2015 Page 6 of 6
Heather Gowin, MA, LPC
MANDATORY DISCLOSURE STATEMENT Name: DOB: Date: In accordance with Colorado State Law, the following information is provided to all persons entering or considering entering psychotherapy. I am a Licensed
Disclosure Statement
Denver Christian School K-12 Counseling Center 3898 S Teller Street Lakewood, CO 80235 1. COUNSELOR INFORMATION Disclosure Statement The following is a disclosure statement for the counseling department
Aleya Littleton, MA, TAP, Adventure Therapist www.wwlcounseling.com (708) 740-0136 DISCLOSURE STATEMENT
Therapist Aleya J. Littleton DISCLOSURE STATEMENT Clinical Supervisor Coming, February 2014. Agency Affiliations and Titles Wild and Wonderful Life Counseling, Therapist. Equinox Counseling Services, MA
Mindful Health Advantage, LLC
8015 West Alameda Ave., Ste 230, Lakewood, CO 80226 - - - CLIENT ADDRESS, CONTACT & FUNDING INFORMATION - - { CLIENT INFORMATION } Last Name First Name M.I. Date of Birth Ethnicity How did you hear about
Amy Davis, M A, L P C
Date: Referred by: May they be contacted to acknowledge your arrival? Yes No Client Information Name: Home Phone: Address: Cell Phone: City: State: Zip: Email: Date of Birth: / / School Name: Grade: School
Client Information Packet
Phone: 303-569-4588 Office locations: Email: tony@equinoxcounselingllc.com Highlands Ranch Medical Plaza II: 9331 South Colorado Blvd., Suite 60 Website: www.equinoxcounselingllc.com Highlands Ranch, CO
Information for New Clients
Information for New Clients Welcome to our practice! This form explains office procedures and relays important information. Your provider will discuss important aspects of the following information with
DISCLOSURE AND CONSENT FORM
SCA INTAKE DOCUMENTS Thank you for your interest in Southwest Counseling Associates. This package contains all the documents you would typically receive when you arrive for your first session with an SCA
One Day at a Time Counseling LLC
One Day at a Time Counseling LLC PSYCHOTHERAPY DISCLOSURE STATEMENT ABOUT MY PSYCHOTHERAPIST: 1. Angelina R. Cordova M.A. Ed, Doctoral Candidate LMFT, ACS, CACIII, RPT-S, CFI, NCPM 8000 E. Prentice Ave.
Client Information and Policy Statement
Page 1 Page 2 Page 3 Client Information and Policy Statement I have compiled a summary of your rights and my responsibilities some of which are dictated by the State of Colorado. Please read them carefully
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
Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 mail@drrebeccaihoward.com
Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 mail@drrebeccaihoward.com CLIENT INFORMATION AND CONSENT Welcome to my practice. This document contains important
Client Brochure, Disclosure Statement, and Consent for Services
DENVER THERAPY & ASSESSMENT Alexandra McDermott, PsyD Licensed Psychologist 600 South Cherry Street, Suite 230, Denver, CO 80246 Alex@DenverTherapyAssessment.com (720) 485-4194 Client Brochure, Disclosure
Group, Family and Individual Counseling
Knippenberg, Patterson & Associates Group, Family and Individual Counseling 2650 S. Eudora St. Denver, CO 80222 Dear Client: We would like to take this opportunity to thank you for choosing our practice
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
Client Name First Last. Address City State Zip. Home Number Mobile Number. Work Number Email. Name First Last. Address City State Zip
CLIENT INFORMATION FORM For Office Use Only Therapist _ CPT Diag Code Fee Start Client DOB _ Client Name First Last Address City State Zip Home Number Mobile Number Work Number Email Parent/Guardian Information:
Brenda Diller, MHR, CHT, HTP www.brendadiller.com Brenda@BrendaDiller.com BrendaDiller@hipaamail.us Office: 970-422-6102 Secure Fax: 970-422-7096
Brenda Diller, MHR, CHT, HTP www.brendadiller.com Brenda@BrendaDiller.com BrendaDiller@hipaamail.us Office: 970-422-6102 Secure Fax: 970-422-7096 Durango Office: Colorado Springs Office: 150 E 9 th Street,
SUBSTANCE ABUSE OUTPATIENT
SUBSTANCE ABUSE OUTPATIENT Service Category Description Substance abuse services - outpatient is the provision of medical or other treatment and/or counseling to address substance abuse problems (i.e.,
Andrew Elman LPC ATR PROFESSIONAL DISCLOSURE STATEMENT
Personal counseling is conducted in various ways, depending on the counselor. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship.
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:
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
MA, PLPC, NCC, CRAADC
Chuck Whittington, MA, PLPC, NCC, CRAADC (816) 200-2262 Mo License #2013038297 4010 Washington, Suite 405 109 C South Madison St Kansas City, MO 64111 Raymore, MO 64083 Supervised by Paul Linville, LPC,
Bert Epstein, Psy.D.
Bert Epstein, Psy.D. 159 Kentucky Street Suite 3 Petaluma, CA 94952 707 242-1989 bert@drbertepstein.com CA License PSY 21404 Office Policies & Agreement for Psychotherapy Services Welcome. Your first visit
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
Explanation of Services and Informed Consent for Treatment
Explanation of Services and Informed Consent for Treatment The following is offered for your information about services at Mind Spa. If you have further questions, please feel free to bring them up with
Relational Connections
INFORMED CONSENT Relational consists of individual, couples, and therapy services provided in Minneapolis with the objective to promote growth in individuals, couples and families. These services are provided
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
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
JEWISH FAMILY SERVICE NOTICE OF PRIVACY PRACTICES
Jewish Family Service takes pride in treating our clients and each other with respect and dignity. Protecting your health information is very important to us. We want you to have a clear understanding
Dr. Beth Gadomski Psychologist, CA License PSY 23658
page 1 of 7 Welcome to my practice. I look forward to our work together. You may have many questions as you begin work with a psychologist who is new to you. In an effort to answer some of those questions,
Involuntary Commitments and Psychiatric Hospitals
Involuntary Commitments and Psychiatric Hospitals What does this mean to You and Your Loved Ones? 515 28 3/4 Road Grand Junction, CO 81501 970.263.4918 WestSpringsHospital.org M-1: INVOLUNTARY COMMITMENT
CALIFORNIA ASSOCIATION FOR ALCOHOL/DRUG EDUCATORS CODE OF ETHICS. Certified Addictions Treatment Counselor (CATC, CATC-I, REGISTRANT, CPS, CCS)
CALIFORNIA ASSOCIATION FOR ALCOHOL/DRUG EDUCATORS CODE OF ETHICS Certified Addictions Treatment Counselor (CATC, CATC-I, REGISTRANT, CPS, CCS) The following Code of Ethics applies to the following individuals:
Healing for the Soul, PC Staff Disclosure Statement POB 25314, Colorado Springs, CO 80936 / 719-590-SOUL(7685)
HFTS Therapist Staff & Credentials: Client name: Healing for the Soul, PC Staff Disclosure Statement POB 25314, Colorado Springs, CO 80936 / 719-590-SOUL(7685) Rev. Jayson L. Graves, M.MFT, Registered
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
Healing Moments Counseling! 9766 Fallon Ave NE Suite 201 Monticello, MN 55362 Phone (763) 732-3351 Fax (763) 322-5026!
Healing Moments Counseling 9766 Fallon Ave NE Suite 201 Monticello, MN 55362 Phone (763) 732-3351 Fax (763) 322-5026 INFORMED CONSENT AND CLIENT CONTRACT Welcome and thank you for choosing Healing Moments
Chaffee County Mental Health Provider Resource List
Emergency services information provided by West Central Mental Health Center West Central Mental Health (WCMH) provides 24 hour emergency services FREE of charge to anyone in Chaffee County, REGARDLESS
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
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:
Notice of Privacy Practices
SHANNON LERACH, Ph.D. Licensed Clinical Psychologist PSY23705 243 N. Highway 101, Suite 16, Solana Beach, CA 92075 Telephone: (619) 817.5320 Fax: (858) 481.1674 Notice of Privacy Practices This Notice
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
Office Hours and Availability
Clinton B. Clark, MA, LPC Counselor/Group Leader PO Box 365; Conifer, CO 80433 Phone: 303-591-7675 / email: clint@clintclarkma.com www.clintclarkma.com Important Information and Policies as You Begin Counseling
Kristin Reiners, MA, LPC-S, RPT, NCC Policies and Procedures
Kristin Reiners, MA, LPC-S, RPT, NCC Policies and Procedures Missed Appointments/Cancellations First and foremost if you need to cancel an appointment and/or reschedule it must be done 24 hours in advance
Notice of Privacy Practices
LiveWell Group 7781 Cooper Road 2 nd floor Suite 5 Cincinnati OH, 45242 Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
Understanding Psychological Assessment and Informed Consent
Understanding Psychological Assessment and Informed Consent You have taken the first step to feel more successful and empowered in your life by choosing to participate in a Psychological Assessment. Thank
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
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
Notice of Privacy Practices
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. Privacy is a very
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
Leonard M. Bohanon, PhD Psychologist
2203 Timberloch Pl., Suite 100 PERSONAL DATA RECORD Client Name: Date of Birth Address: City/State/Zip: Home Phone: Cell Phone: SSN: Work Phone: Other Phone: TXDL: Employer/School: Referred to Our Office
(a) To qualify as a certified supervised counselor alcohol and drug, an applicant shall: (1) BE OF GOOD MORAL CHARACTER;
2015 -Legislative Proposal 1- BOPCT Statute amendment: 1. Revise the BOPCT Statute to remove barriers Introduce legislation in collaboration with the Board of Professional Counselors and Therapists (BoPCT)
MENTAL HEALTH PRACTICE ACT
2013 STATE OF NEBRASKA STATUTES RELATING TO MENTAL HEALTH PRACTICE ACT MARRIAGE AND FAMILY THERAPY PROFESSIONAL COUNSELING SOCIAL WORK Department of Health and Human Services Division of Public Health
Connections Counseling, L.L.C. Couple/Family s Personal Information
Name (s): SS#(indicate name): Home Address: Connections Counseling, L.L.C. Couple/Family s Personal Information DOBs/Ages: How were you referred? Specify names of which client for all questions below:
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:
HIPAA Privacy Rule CLIN-203: Special Privacy Considerations
POLICY HIPAA Privacy Rule CLIN-203: Special Privacy Considerations I. Policy A. Additional Privacy Protection for Particularly Sensitive Health Information USC 1 recognizes that federal and California
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
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
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
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
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
PATIENT INFORMATION Please complete for self or minor child responsible party information below. Street Apt. City State Zip
Name: Address: E-mail: Phone numbers: Lisa Dungate, Psy.D., M.A. Mental Health Counseling PATIENT INFORMATION Please complete for self or minor child responsible party information below DOB: Street Apt.
Melanie Bierenbaum, Psy.D. Licensed Psychologist 3040 E. Cactus Rd, Suite A Phoenix, AZ 85032 Office: 602-769-2773
Service Agreement and Treatment Consent Welcome and thank you for choosing to work with Dr. Bierenbaum. This document contains important information about professional services, the psychologist-patient
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.
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.
STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION
STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION TITLE GRADE EEO-4 CODE MENTAL HEALTH COUNSELOR V 43* B 10.135 MENTAL HEALTH COUNSELOR IV 41* B 10.137
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
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
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
LG/LCADC (Licensed Graduate or Licensed Clinical Alcohol and Drug Counselor) Pre-Application Credentials Evaluation Instructions
Maryland Board of Professional Counselors and Therapists 4201 Patterson Avenue Baltimore, MD 21215 410-764-4732 or 410-764-4740 www.dhmh.maryland/bopc/ LG/LCADC (Licensed Graduate or Licensed Clinical
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
ARTICLE ## LICENSED MENTAL HEALTH COUNSELOR
ARTICLE ## LICENSED MENTAL HEALTH COUNSELOR Section #####1. Definitions. Section #####2. Qualifications for Licensure. Section #####3. Exceptions to Licensure. Section #####4. Scope of Practice. Section
HOUSE BILL No. 2577 page 2
HOUSE BILL No. 2577 AN ACT enacting the addictions counselor licensure act; amending K.S.A. 74-7501 and K.S.A. 2009 Supp. 74-7507 and repealing the existing section; also repealing K.S.A. 65-6601, 65-6602,
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
Helping You Choose a Counselor or Therapist
Helping You Choose a Counselor or Therapist There are times when personal, work, or family problems make it hard to enjoy life. Maybe you're having trouble sleeping or concentrating at work. Perhaps you
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
ROGER D. BUTNER, PHD, LMFT - Murphy Toerner and Associates, Inc.
ROGER D. BUTNER, PHD, LMFT - Murphy Toerner and Associates, Inc. I know you have several pages of paperwork to complete, so I will only take a few moments of your time now to share some important details
2. Can an individual with a temporary certificate for advanced practice social work provide psychotherapy under supervision?
STATE OF WISCONSIN Mail to: Department of Safety and Professional Services PO Box 8935 1400 E Washington Ave. Madison WI 53708-8935 Madison WI 53703 Email: dsps@wisconsin.gov Web: http://dsps.wi.gov Governor
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
PRACTICE STANDARDS COMMITTEE NASW, COLORADO CHAPTER. Sandra L. Holman, PhD, BCD, LCSW, Chair GUIDELINES FOR INFORMED CONSENT IN SOCIAL WORK PRACTICE
PRACTICE STANDARDS COMMITTEE NASW, COLORADO CHAPTER Sandra L. Holman, PhD, BCD, LCSW, Chair GUIDELINES FOR INFORMED CONSENT IN SOCIAL WORK PRACTICE Informed consent is an ethical doctrine of social work
Virginia Beach Coaching & Counseling, LLC
Virginia Beach Coaching & Counseling, LLC Informed Consent for Counseling of Individuals Introduction to the Agency Virginia Beach Coaching & Counseling, LLC. (VBCC) is a private coaching and counseling
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
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
Certified Tobacco Treatment Specialist
Certified Tobacco Treatment Specialist Applicant Name The CERTIFIED TOBACCO TREATMENT SPECIALIST is not an independent clinical practice credential and should only be used for work within health care or
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
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
Shorehaven Behavioral Health, Inc Post Degree Training for Masters and PhD/PsyD Trainees
Shorehaven Behavioral Health, Inc Post Degree Training for Masters and PhD/PsyD Trainees Wisconsin Training Rules In Wisconsin, a professional who has completed the Masters degree and procures the training
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
(2) Minutes shall be maintained for advisory board meetings.
ACTION: Refiled DATE: 08/18/2015 9:45 AM 5122-29-12 Driver intervention program. (A) A driver intervention program is a program of screening, education, and referral for individuals who are arrested or
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
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:
Agreement for Therapy and Informed Consent
Agreement for Therapy and Informed Consent Welcome to the counseling program of St. Joseph Family Center. This Agreement for Therapy contains important information about our professional services and business
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.
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
9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com. Welcome Friend!
9525 Katy Freeway, Suite 312 Houston, Texas 77024 Phone (713) 463-9449 Fax (713) 463-7181 www.bhchouston.com Welcome Friend! Thank you for your interest in pursuing counseling services in this office.
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006
Jerry M. Ruhl Ph.D. Clinical Psychologist (Texas #34359) 5200 Montrose Blvd. Houston, TX 77006 CELL (937) 684-7746 PLEASE USE THIS NUMBER TO SCHEDULE OR CHANGE APPOINTMENTS INFORMED CONSENT FOR TREATMENT
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
N A S W National Association of Social Workers ~ California Chapter
N A S W National Association of Social Workers ~ California Chapter Steps to a California LCSW for Out-of-State LCSWs Prior to Jan 1, 2016 BBS Announcement: LCSW Exam Restructure Scheduled January 1, 2016
PSYCHOTHERAPY: HOW TO GET STARTED
PSYCHOTHERAPY: HOW TO GET STARTED I didn t want to talk about my problems with someone I didn t know. Then I learned how common it is to initially feel hesitant and to even try several therapists before
OFFICE POLICIES AND PROCEDURES Acknowledgement Form
OFFICE POLICIES AND PROCEDURES Acknowledgement Form Staff Therapists: David Zachau, M.A., P.C.C.-S Patricia Chmura, M.Ed., P.C.C.-S Christine Saladin, L.P.C.C. Mary Migra, LISW Jennifer Hodgson, M.Ed.,
Therapist: RT AL SR DV LB CL NP INT. Name of Child s School: Is child seeing a guidance counselor? YES NO If yes, name of counselor:
224 East Main Street Lexington, SC 29072 (803) 808-5222 E-mail LCC@LexingtonChristianCounseling.org Date: I. Client Information Primary Client Name Birthdate SSN Hm. Phone # Wk Phone # Cell Phone # Messages
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