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

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1 : Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas Client Intake Information Client Name: Street Address: City: State: ZIP: of Birth: Gender: Home Phone: OK to leave message? Yes No Office Phone: OK to leave message? Yes No Mobile Phone: _ OK to leave message? Yes No OK to use text messaging? Yes No E- mail address: OK to use e- mail for messages? Yes No Marital Status: Single Married Divorced Widowed Cohabitating If previously married, when? How long? Children (names and ages): Custody of children from former marriage (names and ages): Occupation: Employer:

2 Employer s Address Religious preference How much influence does spirituality have in your day- to- day living? Not at all Very much For what issue(s) are you requesting counseling today (please include when symptoms began and how long they have lasted)? What has happened recently that has led you to seek counseling for the issue(s)? Have you sought counseling or psychiatric treatment before? When? What was the result? Present Medications (for mental or physical health): _ Current Primary Care Doctor: Phone: last seen: Please indicate if there is additional medical and/or personal information not previously requested that you feel should be included:

3 Do you have any current or previous legal issues such as driving under the influence, court ordered treatment, conviction of a crime, civil lawsuits, etc? If yes, explain: Who referred you? By signing below you certify that the information given is correct to the best of your knowledge. Client s Signature

4 Informed Consent and Treatment Agreement For Outpatient Counseling Background of Clinician: I am a licensed pastor. I have a Bachelor s degree from Texas Christian University, a law degree from Baylor University, a Master s of Arts in Christian Education from Dallas Theological Seminary, and a Master s of Arts in Biblical Counseling, also from Dallas Theological Seminary. I am a candidate for certification in sex addiction (CSAT) under the supervision of Shawn Jeffries, PhD. I am also certified as an A.R.I.S.E interventionist. Risks and Benefits of Psychotherapy: Most clients seeking counseling are experiencing psychological and / or spiritual issues that are causing internal distress and problems in relationships. The goal of counseling is to reduce the distress associated with these issues. Some individuals may not experience relief and may even experience either an exacerbation of issues or even new and different issues during counseling. If this happens a recommendation will be made for different or more intensive treatment. Clients in counseling will benefit from the support of family, friends, and a vibrant spiritual community. Clients may also benefit from other types of modalities, such as experiential treatment methods and outside support groups, such as 12- step groups. Where the client desires referrals can be made. Philosophy of Counseling: The philosophy of counseling used in our office is based on the following principles: (1) we strive to maintain the highest clinical and ethical standards, and (2) we seek to maintain biblical integrity in our approach to therapy. However, we recognize that your belief system may differ from ours and while we are committed to counseling principles compatible with the Christian faith, our beliefs will not be imposed on any client against his or her wishes. It is your therapy and you will make the decision with regard to the level spirituality that is offered. Services Offered: We offer the following counseling services: Pastoral, Individual, Group, Pre- marital, Marital, and Family Counseling. The counselor and the client(s) will mutually decide which specific form of counseling and the particular theoretical orientation that is best suited for each person as needs are assessed throughout the course of counseling. Referrals can be made if an expert in an area in which our counselors are not proficient would best serve you. Medical Issues: I am not a medical doctor and I am not licensed to recognize or diagnose medical conditions. It is our advice that you seek a medical examination to determine whether any of your symptoms are as a result of a physical rather than psychological or spiritual origin.

5 I am also not a psychiatrist, and I cannot prescribe psychiatric medications. You will be referred to a psychiatrist for a consultation if it appears that medications may be helpful. Professional Records: The law and ethical codes require that records of treatment be kept. You are entitled to a copy of these records unless it is believed that you would be emotionally damaged by seeing them, in which case they will be sent to the counselor of your choice to review them with you. These records are kept in a locked cabinet behind a locked door. Confidentiality: All communication is confidential and your permission is necessary to release any information to outside persons except for limitations required by the laws of the state of Texas. Exceptions to confidentiality include (a) reasonable suspicion of incidents of child abuse or neglect; (b) incidents of elder abuse, neglect, or exploitation; or (c) a determination that you are a danger to yourself or others; (d) a request from you in writing, directing me to deliver confidential information to a specified individual or agency; or (e) I am ordered by a court to disclose confidential information. In addition, with your permission, your information may be shared with other clinicians if to do will enhance your treatment and the professional expertise of your counselor. This includes: (a) collaborating and consulting with associates within this counseling group, all of whom agree to maintain confidentiality of your information solely within the group; (b) when I am engaged in supervision with a qualified supervisor for purposes of improving my clinical expertise, in which case the supervisor will have access to your information but is bound by the same confidentiality laws as I am; or (h) in the event I am unavailable and another professional is providing emergency care for my clients, in which case this professional may require access to client files. Boundaries: In order to get the most out of counseling, the therapeutic relationship between client and counselor is of utmost importance. Our goal is to make that relationship as efficacious as possible by keeping that relationship primary and not confusing it with other relationships. In non- therapeutic settings such as at restaurants, shopping, churches or other social settings, I will not be able to discuss counseling issues with you. I want to make sure you understand that I am not trying to be rude when I do not initiate a conversation outside the office; I am just complying with the ethical rules that bind our profession. Fees: The normal counseling session is 50 minutes. The fee for a session is $ You may cancel an appointment as long as cancellation occurs more than 24 hours before the scheduled appointment. If an appointment is cancelled less than 24 hours before the appointment, or you

6 do not show up for the appointment without cancelling, you will be charged the full session rate unless that time slot can be filled by another client. However I assume no obligation to try to fill the slot. We do not accept insurance and do not file for benefits for clients. Upon request we will prepare a statement for you to file for out- of- network insurance benefits, and all payments will be directed to you. Agreement: I,, the undersigned, have received, read and understood the information contained in this Informed Consent and Treatment Agreement For Outpatient Counseling. By my signature below, I voluntarily agree to receive counseling services with Chris Groff, JD, MA, Licensed Pastor through Fort Worth Counseling and Intervention. 1. I have rights as a client of counseling services, and have received and read a description of my rights contained on the Informed Consent and Treatment Agreement For Outpatient Counseling sheet. I may obtain additional information regarding rights from the Texas Department of Health Services if I so desire. 2. I understand I will be participating in the development of my treatment. 3. I understand my active participation is crucial to the outcome of counseling services received; I also understand that a favorable outcome is not guaranteed. Client or Legal Guardian Counselor s Signature Client s emergency contact Contact s phone # For questions involving counseling in the State of Texas: Texas State Board of Examiners of Professional Counselors Texas Board of Social Work Examiners and Marriage and Family Therapists 1100 West 49 th Street Austin, TX (512) , (512) or (512)

7 Special Agreement, Consent and Disclosure for Treatment of Sex Addiction Popular media and some health care professionals have used labels such as sex addiction, hypersexual behavior, compulsive sexual behavior, or out of control or problematic sexual behavior to describe a pattern of repetitive and intense preoccupation with sexual thoughts, urges, or behaviors. Sexually addicted clients often report using sex frequently to cope with stressful experiences in their lives, or to escape unpleasant mood states such as loneliness, anxiety, boredom, or depression. These patterns of behavior can contribute to a number of undesirable consequences. Despite these consequences, some people report being unable to control or reduce the frequency of these sexual behaviors and they continue to engage in sexual activities that that place themselves or their loved ones at risk for physical, emotional, financial, or legal harm. These patterns of behavior can contribute to feelings of shame, guilt, sadness, regret, and worry about being exposed or caught. In addition, significant problems with personal relationships, social events, family, work, and other important areas of life can be adversely affected. Labeling these behaviors as sex addiction can help provide a framework for understanding the challenges and problems experienced by some people. The label also helps researchers understand the issues associated with sex addiction and allows health care professionals to communicate with each other about the latest developments in client care. While labels like sex addiction have value in clinical work such as treatment planning and case conceptualization, the diagnosis of sex addiction is not yet recognized or sanctioned as a psychiatric disorder by the American Psychiatric Association, nor is it included in the Diagnostic Statistical Manual of Mental Health Disorders Fifth Edition as a psychiatric diagnosis. When these labels are used in our work together, they do not refer to a psychiatric diagnosis. Although sex addiction currently is not recognized as a psychiatric or psychological disorder, research studies have found that clients seeking help for sexual addiction frequently manifest other, co- occurring mental health disorders such as mood, anxiety, substance- related, and attention deficit disorders. As a result, where appropriate to do so, our work together may include a diagnostic evaluation or assessment to determine whether you may be presenting with any other disorder. We will address any other disorder you may have concurrently with our treatment for sex addiction.

8 I,, the undersigned, have received, read and understood the information contained in this Agreement, Consent and Disclosure for Treatment of Sex Addiction. By my signature below, I voluntarily agree to receive counseling services with Chris Groff, JD, MA, Licensed Pastor through Fort Worth Counseling and Intervention. Client or Legal Guardian Counselor s Signature

9 Client Payment Agreement Please note that payment is due at the time services are rendered. When you make an appointment, I will set that time aside for you and will not schedule another client for that time. Because I am holding that time for you, please note that if a cancellation is made less than 24 hours before the appointment time, the full billing rate will be charged. Cancellation and rescheduling can be done by calling or texting (817) Cancellation via to also is acceptable. Although you are encouraged to call your counselor in an emergency, you will be billed at your regular rate in quarter hour increments for any calls during which you receive counseling. If for any reason your counselor is asked to appear in court on your behalf, you will be billed at the regular rate for time incurred in such court appearance, including preparation for testimony and travel. You will be billed ahead of time in half- day increments. All sessions are 50 minutes. The fee for the initial and all subsequent sessions is $ per 50- minute session.

10 A credit card is acceptable payment, and will be used for payment if you either desire to make it the primary payment method, or if you leave the office without paying by some other method. To ensure payment, please complete the following: Credit card number: Expiration Month Year Security Code Billing address: Street: City State Zip Name as it appears on the card: By signing below you are indicating that you have read and agree to the above Client Payment Agreement and that you also authorize Chris Groff, MA, Licensed Pastor, to release any information necessary for you to secure insurance reimbursement for fees you have paid to Fort Worth Counseling and Intervention: Client s Signature Counselor s Signature

11 Release of Information I, _ voluntarily authorize Chris Groff, JD, MA, Licensed Pastor to release and exchange oral and written information to at the following phone number and address: regarding my counseling sessions with Chris Groff, JD, MA, Licensed Pastor. The information will be used for the following purposes: Follow- up care Placement My treatment with Fort Worth Counseling and Intervention insurance determinations Other (specify) The type of information to be released will be the following: of treatment Summary of treatment Diagnosis Psychological assessments Other (specify) I understand that my refusal to authorize release of my information does not necessarily entail termination of my treatment with Chris Groff, JD, MA, Licensed Pastor. I also understand that by giving my consent, as demonstrated by filling out this form, I have the right to inspect and copy the information that I have authorized to be released. This authorization is valid until (or one year from the date of signing.) Client s Signature Parent or Guardian s Signature

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