1 Information for Clients Welcome to Sterman Counseling and Assessment. We appreciate the opportunity to be of assistance to you. This packet answers some questions about therapy services. It is important that you know how we will work together. We believe our work will be most helpful to you when you have a clear idea of what we are trying to do. This packet talks about the following in a general way: What the risks and benefits of therapy are. What the goals of therapy are, and what some general treatment approaches are like. How long therapy might take. How much my services cost, and how money matters are handled. Other important areas of our relationship. After you read this packet we can discuss, in person, how these issues apply to your situation. This packet is yours to keep and refer to later. Please read all of it and mark any parts that are not clear to you. Write down any questions you think of, and we will discuss them at our next meeting. When you have read and fully understood this packet, I will ask you to sign it at the end, as well as an acknowledgement form that will be retained in your records. About Psychotherapy Because therapy involves a significant amount of time, money, and energy, it is important to choose a therapist carefully. You should feel comfortable with the therapist you choose, and hopeful about the therapy. When you feel this way, therapy is more likely to be very helpful to you. By the end of the first or second session, your therapist will talk with you about how he/she views your situation, and possible ways to proceed. Therapy works best as a partnership with the therapist. You define the problem areas to be worked on; the therapist uses some special knowledge to help you make the changes you want to make. Psychotherapy is not like visiting a medical doctor. It requires your very active involvement. It requires your best efforts to change thoughts, feelings, and behaviors. For example, your therapist may encourage you to talk about important experiences, what they mean to you, and what strong feelings are involved. This is one of the ways you are an active partner in therapy. You are encouraged to work with your therapist to formulate a treatment plan, which includes areas to work on and goals. This treatment plan should be reviewed periodically to look at progress and goals, and to make any changes that may be helpful. Many clients initially schedule weekly therapy appointments for the first several months, followed by a period of decreasing frequency. Therapy then usually comes to an end, in a process referred to as termination. Because termination can be a very valuable part of the process, stopping therapy should not be done casually, although either you or your therapist may decide to end it if we believe it is in your best interest. If you wish to stop therapy at any time, you are asked to agree now to meet then for at least one session to review your therapy experience. You and your therapist can then review goals, the work done, any future work that needs to be done, and any choices. If you would like to take a break from therapy to try it on your own, this should be discussed. The Benefits and Risks of Therapy As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk
2 that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. In addition, some people in your community may mistakenly have a negative view toward those seeking therapy. Also, clients in therapy may have problems with people important to them. Sometimes, too, a client s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the issues are addressed. Clients relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives. Consultations If you could benefit from a treatment your therapist cannot provide, you will be assisted in getting it. You have a right to ask about such other treatments, their risks, and their benefits. Based on what an exploration of your concerns and problems, you may be asked to seek a medical exam or to talk with a psychiatrist about the possible use of medication. If so, your therapist will discuss the reasons with you, so that you can decide what is best. If for some reason treatment is not going well, your therapist may suggest you see another therapist or another professional in addition. As a responsible person and ethical therapist, your therapist cannot continue to treat you if the treatment is not working for you. If you wish for another professional s opinion at any time, or wish to talk with another therapist, you will be assisted in finding a qualified person, and your therapist will provide him or her with the information needed. What to Expect from Our Relationship As a professional, your therapist will use his/her best knowledge and skills to help you. This includes following the standards of the American Psychological Association (APA). In your best interests, APA puts limits on the relationship between a therapist and a client, and will be adhered to. The following is an explanation of these limits. First, your therapist is licensed and trained to practice psychotherapy not law, medicine, finance, or any other profession. Thus, your therapist is not able to give you good advice from these other professional viewpoints. Second, state laws and the rules of the APA require confidentiality (that is, privacy). This means that your therapist will try not to reveal who my clients are. This is part of the effort to maintain your privacy. If you see your therapist on the street or socially, he/she may not say hello or talk to you very much. This will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship. Third, in your best interest, and following the APA s standards, your therapist can only be your therapist. No other roles are possible. Your therapist cannot, now or ever, be a close friend or socialize with any client. He/she cannot be a therapist to someone who is already a friend. He/she can never have a sexual or romantic relationship with any client during, or after, the course of therapy. He/she cannot have a business relationship with any of client, other than the therapy relationship.
3 About Confidentiality All information will be treated with the utmost care. It is your legal right that your sessions and records about you be kept private. That is why you are asked to sign a release-of-records form before your therapist can talk about you or send records about you to anyone else. In general, no one will be told what you disclose in therapy, or even that you are in therapy at all. In all but a few rare situations, your confidentiality (that is, your privacy) is protected by state law and by the rules of psychology. Here are the most common cases in which confidentiality is not protected: 1. If you were sent by a court or an employer for evaluation or treatment, the court or employer expects a report from your therapist. If this is your situation, please talk with your therapist before you say anything you do not want the court or your employer to know. You have a right to disclose only what you are comfortable with telling. 2. If you are involved with a civil or criminal suit, and you tell the court that you are receiving therapy, your therapist may then be ordered to show the court your records. Please consult your lawyer about these issues. 3. If you make a serious threat to harm yourself or another person, the law requires your therapist to try to protect you or that other person. This usually means telling others about the threat. Your therapist cannot promise never to tell others about threats you make. 4. If there is reason to believe a protected person has been or will be abused or neglected, this must be reported to the authorities. Protected persons are children, elderly adults, and disabled individuals. There are two situations in which your therapist might talk about part of your case with another therapist. Your understanding and agreement is requested to allow these two situations. First, when your therapist is away from the office for a few days, a trusted fellow therapist covers. This therapist will be available to you in emergencies. Therefore, he or she needs to know about you. This therapist is bound by the same laws and rules of confidentiality. Second, your therapist sometimes consults other therapists or other professionals about clients, which assists with ensuring high-quality treatment. These persons are also required to keep your information private. Your name will never be given to them, and they will be told only as much as they need to know to understand your situation. Except for the situations described above, the office staff and your therapist will always maintain your privacy. You are asked not to disclose the name or identity of any other client being seen in this office. The office staff makes every effort to keep the names and records of clients private. The staff and your therapist will try never to use your name on the telephone, if clients in the office can overhear it. All staff members who see your records have been trained in how to keep records confidential. If your records need to be seen by another professional, or anyone else, this will be discussed with you. If you agree to share these records, you will need to sign a release form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits. You may read this form at any time. If you have questions, please ask. It is office policy to destroy clients records 7 years after the end of our therapy. Until then, your case records will be kept in a safe place.
4 If your therapist must discontinue the therapy relationship because of illness, disability, or other presently unforeseen circumstances, you are asked to agree to transfer your records to another therapist who will assure their confidentiality, preservation, and appropriate access. As part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and treatment methods. It will become part of your permanent medical record. You will be informed if this should occur and what the company has asked for. Please understand that this office has no control over how these records are handled at the insurance company. Office policy is to provide only as much information as the insurance company will need to pay your benefits. You may request to review your own records at any time, with your therapist or other identified individual. You may add to them or correct them, and you can have copies of them. Please understand and agree that you may not examine records created by anyone else and sent to the office. In some very rare situations, some parts of your records may be temporarily removed before you see them, such as if it is felt that the information will be harmful to you. In such a case, this will be discussed with you. About Appointments Sessions are 45 to 50 minutes. Typically, sessions will be scheduled once per week, at least during the earlier stages of therapy. Meetings will be scheduled for both your and your therapist s convenience, though efforts will be made to schedule appointments at consistent times. You will be told well in advance of vacations or any other times sessions are unavailable, except in unusual circumstances. An appointment is a commitment to the work. You and your therapist agree to meet here and to be on time. You are asked for understanding if your therapist is ever unable to start on time. In such a case, you will receive the full time agreed to. If you are late, you will probably be unable to meet for the full time, because it is likely that another appointment is scheduled after yours. A cancelled appointment delays our work. Please try not to miss sessions if you can possibly help it. When you must cancel, please let your therapist know as far in advance as possible, at least 24 to 48 hours in advance. Your session time is reserved for you, and it is often not possible to fill a cancelled session without advance notice. If you start to miss a lot of sessions, you may be charged for the lost time unless your therapist is able to fill the time. You will be charged for sessions cancelled with less than 24 to 48 hours notice, for other than the most serious reasons. Your insurance will not cover this charge. Please do not bring children with you if they are young and need babysitting or supervision, which are not able to be provided. Fees, Payments, and Billing Payment for services is an important part of any professional relationship. This is true in therapy, as well; one treatment goal is to make relationships and the duties and obligations they involve clear. You are responsible for seeing that services are paid for. Meeting this responsibility shows your commitment and maturity. Current regular fees are as follows. You will be given advance notice if my fees should change. Regular therapy services: The initial assessment session is $150. For a session of 45 to 50 minutes, the fee is $130. When payment arrangements have been established with a third-party payer (e.g., your insurance company), these arrangements often include a co-payment. Payment is requested upon arrival. This arrangement helps maintain focus on goals, and so it works best. Other payment or fee arrangements must be worked out before the end of the first meeting.
5 Telephone consultations: Telephone consultations may be suitable or even needed at times in our therapy. If so, the charge will be the regular fee, prorated over the time needed. If long telephone conferences with other professionals are needed as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about all this, please be sure to discuss it in advance so a policy can be determined that is mutually comfortable. Of course, there is no charge for calls about appointments or similar business. Psychological testing services: $130 per hour. Psychological testing fees include the time spent with you, the time needed for scoring and studying the test results, and the time needed to write a report on the findings. The amount of time involved depends on the tests used and the questions the testing is intended to answer. Reports: You will not be charged for time spent making routine reports to your insurance company. However, you will be billed for any extra-long or complex reports the company might require. The company will not cover this fee. Other services: Charges for other services, such as hospital visits, consultations with other therapists, home visits, or any court-related services (such as consultations with lawyers, depositions, or attendance at courtroom proceedings) will be based on the time involved in providing the service at the regular fee schedule. Some services may require payment in advance. Our agreed-upon fee-paying relationship will continue as long as services are provided to you, unless you indicate otherwise to your therapist in person, by telephone, or by certified mail that you wish to end it. You have a responsibility to pay for any services you receive before you end the relationship. Because all payment is expected at the time of session, bills are not usually sent. However, if billing is part of the agreement, you are asked to pay the bill within 5 days of receiving it. If you request, at the end of each month, you may be given a statement. The statement can be used for health insurance claims, as described in the next section. It will show all of sessions, the charges for each, how much has been paid, and how much (if any) is still owed. At the end of treatment, and when you have paid for all sessions, you may be given a final statement for your tax records. If you think you may have trouble paying your bills on time, please discuss this with your therapist. Your therapist will also raise the matter with you so a solution can be identified. If your unpaid balance is equal to four sessions, you will be notified by mail. If it then remains unpaid, therapy may be discontinued. Fees that continue unpaid after this may be turned over to small-claims court or a collection service. If there is any problem with charges, billing, your insurance, or any other money-related point, please bring it to your therapist s attention. He/she will do the same with you. Such problems can interfere greatly with the therapeutic work. They must be worked out openly and quickly. If You Have Traditional Health Insurance Coverage Because your therapist is a licensed mental health professional, many health insurance plans will help you pay for therapy and other services offered. Because health insurance is written by many different companies, it is important that you read the relevant portions of your plan s booklet, often identified as Outpatient Psychotherapy or Treatment of Mental and Nervous Conditions. You may also call your employer s benefits office to find out what you need to know. If your health insurance will pay part of the fee, your therapist will help you with your insurance claim forms. However, please keep two things in mind:
6 1. Your therapist had no role in deciding what your insurance covers. Your employer decided which, if any, services will be covered and how much you (and your therapist) will be paid. You are responsible for checking your insurance coverage, deductibles, payment rates, co-payments, and so forth. 2. You not your insurance company or any other person or company are responsible for paying the fees we agree upon. If you ask to bill another individual or an insurance company, and payment is not received on time, this payment will be expected from you. To seek payment from your insurance company, you must first obtain a claim form from your employer s benefits office or call your insurance company. Complete the claim form. Then attach the statement to the claim form and mail it to your insurance company. The statement already provides the information asked for on the claim form. If You Have a Managed Care Contract If you belong to a health maintenance organization (HMO) or have another kind of health insurance with managed care, decisions about what kind of care you need and how much of it you can receive will be reviewed by the plan. The plan has rules, limits, and procedures that should be discussed. Please bring your health insurance plan s description of services to one of your early meetings, so that you can talk about it and decide what to do. Your therapist will provide information about you to your insurance company only with your informed and written consent. This information may be sent by mail or by fax. The office will try its best to maintain the privacy of your records, but you are asked not to hold the office or your therapist responsible for accidents or for anything that happens as a result. All insurance carriers claim to keep the information they receive confidential, and there are federal laws about its release. The laws and ethics that apply to me are much stricter than the rules that apply at present to MCOs. If You Need to Contact Your Therapist Although your therapist is in the office several days each week, phone calls are usually not answered when with a client. You can always leave a message with the receptionist or on voic , and your call will be returned as soon as possible. Generally, messages are returned daily except on Sundays and holidays. If you have an emergency or crisis, tell this to the receptionist, who will try to contact your therapist. If you have a crisis and cannot reach your therapist or the receptionist immediately by telephone, you or your family members should call 911 or go to your nearest hospital emergency department. There are several hospitals in the area. A list of these hospitals and their telephone numbers is available upon request. If Your Therapist Needs to Contact Someone about You If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you perhaps a relative, spouse, or close friend. I am also required to contact this person, or the authorities, if I become concerned about your harming someone else. Please make sure to include this information as you complete the intake packet. Other Points If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first.
7 Doing follow-up and outcome research is always educational. As a professional therapist, I naturally want to know more about how therapy helps people. To understand therapy better, I must collect information about clients before, during, and after therapy. Therefore, I am asking you to help me by filling out some questionnaires about different parts of your life-relationships, changes, concerns, attitudes, and other areas. I ask your permission to take what you wrote on these questionnaires and what I have in my records and use it in research or teaching that I may do in the future. If I ever use the information from your questionnaire, it will always be included with information from many others. Also, your identity will be made completely anonymous. Your name will never be mentioned, and all personal information will be disguised and changed. After the research, teaching, or publishing project is completed all the data used will be destroyed. If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies. Statement of Principles and Complaint Procedures It is the intention of your therapist to fully abide by all the rules of the American Psychological Association (APA) and by those of his/her state license. Problems can arise in the relationship, just as in any other relationship. If you are not satisfied with any area of the work, please raise your concerns at once. Every effort will be made to hear any complaints you have and to seek solutions to them. If you feel that any therapist has treated you unfairly or has even broken a professional rule, please tell your therapist. You can also contact the state or local psychological association and speak to the chairperson of the ethics committee. He or she can help clarify your concerns or tell you how to file a complaint. You may also contact the Virginia state board of psychologist examiners, the organization that licenses those of us in the independent practice of psychology. In this practice, there is no discrimination against clients because of any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a personal commitment, as well as being required by federal, state, and local laws and regulations. Steps will always be taken to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately. We truly appreciate the chance you have given us to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with our services as we proceed, we (like any professional) would appreciate your referring other people who might also be able to make use of our services. Signature of client Printed name of client Date
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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
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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
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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
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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
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
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
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.,
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
Bert Epstein, Psy.D. 159 Kentucky Street Suite 3 Petaluma, CA 94952 707 242-1989 email@example.com CA License PSY 21404 Office Policies & Agreement for Psychotherapy Services Welcome. Your first visit
JACQUELINE HOOD, PH.D. Licensed Psychologist Licensed Specialist in School Psychologist 972-827-7921 www.dallaschildpsychologist.com Consent Form Welcome to my practice. This document contains important
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
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
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,
Introduction Laura Bosworth, MFT, MS Counseling Licensed Marriage and Family Therapist License Number MFC 53156 12881 Knott St., #109, Garden Grove, CA 92841 562-716-3461 www.laurabosworthmft.com AGREEMENT
OUTPATIENT SERVICES CONTRACT and DISCLOSURE STATEMENT Welcome to Northwest Neurobehavioral Institute (NNI). This document contains important information about our professional services and business policies.
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
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.
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
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:
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:
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
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
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
Code of conduct for Healthcare Support Workers Working to standard: a code of conduct for support workers in health care 1. Introduction 1.1 Welcome to this code of conduct for support workers in health
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Sandra Mote, MS, CS, ARNP Patient Name (please print): Welcome to the psychotherapy and psychiatric
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.
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
Azmaira Maker, Ph.D. Licensed Clinical Psychologist (PSY 21570) 12625 High Bluff Drive, Suite 104 San Diego, CA 92130 Tel: (858) 531-1122 Fax: (866) 861-7731 www.drmaker.net Thank you for inquiring about
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully. This practice is required by law to
Child Personal Information Child s Name: Date: Age: DOB: / / Gender: M F Race: Address: Apt: City: State: Zip Code: Father s Name: Date of Birth: / / Age Father s Occupation: Phone Number: Mother s Name: