1 INFORMATION FOR CLIENTS Psychotherapy Practice Information Brochure Kate Miller, PsyD, HSPP Clinical Psychologist Director, Under the Umbrella, LLC 4315 E. 3 rd St. Bloomington, IN (812) Welcome to my practice. I am grateful to have the opportunity to be of help to you. This brochure provides some information and answers some questions about therapy in general and my specific practice. Please read it thoroughly and bring it with you to our first session. We can discuss in person any questions that you have, and I will ask you to sign a copy for my files. My Background I received a bachelor s degree in psychology and English from Indiana University. I received my masters degree and psychology doctorate degree from the University of Indianapolis with a specialization in child and adolescent psychology. I am a licensed psychologist in the state of Indiana (license number A). I am trained as a generalist with a subspecialty in eating disorders and group psychotherapy. I have been providing therapy, other mental health clinical services, and eating disorder treatment since 2010 at university counseling centers at Virginia Tech, Purdue University, and the University of Pittsburgh. I joined Under the Umbrella, a multidisciplinary treatment group, in June Because eating disorders are a multi-systemic concern, I highly value the involvement of multiple providers. This may include nutrition, psychiatry, medical, and/or kinesiology. Jessi Roman, BS, is a dietician and affiliate of Under the Umbrella. Craig Paiement, a kinesiologist, specializes in sport psychology and exercise physiology and is an affiliate of Under the Umbrella. Christy Duffy, PhD, is a psychologist and director of Under the Umbrella. About Psychotherapy I take a holistic and integrative approach to therapy, and believe it is important to consider the framework of each person s unique experience and cultural background. My approach is tailored to meet the needs of individual clients based on their presenting concerns and goals for therapy. I most commonly use methods associated with cognitive behavioral and psychodynamic theories. Although my approach may differ depending on your concerns, I always place a strong importance upon the therapeutic relationship, and I value any feedback you may have about our relationship and your experience in therapy. During your first appointment, we will discuss your goals and expectations for therapy and what I believe may be the best way to approach working on your concerns. The frequency
2 of our meetings will differ depending on different factors, and we will discuss this more in detail during our first meeting. Being an active, willing participant in therapy is important in order to meet your goals. Collaboration between you and myself will be essential in addressing your presenting concerns. In order to receive the most benefit from the process of therapy, you will have to work on things we discuss outside of sessions, including recommendations and homework assignments, but the final decision is yours and yours alone. If we decide that my practice seems a good match, we will discuss your goals, the frequency with which we will meet, and whether supplementary consultations (such as with a dietician, physician or psychiatrist) are warranted. If we decide that my practice is not a good match, I will offer you referrals to other therapists. It is important to know that while change typically it takes time, is characterized by forward and backward movements, and takes consistent focus and effort. The Benefits and Risk of Therapy As with any powerful treatment, there are some risks as well as many benefits associated with therapy. It is helpful to carefully consider both the risks and benefits when making treatment decisions. For example, in therapy there is a risk clients will, for a time, have uncomfortable or increased levels of anxiety, guilt, anger, frustration, sadness, loneliness, helplessness, or other difficult feelings. Clients may recall unpleasant memories, and these feelings or memories may bother a client at work or in school. Sometimes a client s problems may temporarily worsen after the beginning or 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 for you. While you consider these risks, you should also know the benefits of therapy have been shown in numerous well-designed research studies. Therapy often leads to significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. Personal goals and values may become clearer, and the ability to live out these goals and values may become easier. Clients may grow in many directions as people, in close relationships, in work or schooling, and in the ability to have increased joy and ease in life. I do not take on clients that I do not think I can help. Therefore, I will enter our relationship with optimism about our progress. Consultations and Collaboration Individuals suffering from eating disorders are impacted medically, nutritionally, interpersonally, and psychologically. Because of this, I highly value collaboration with other providers. Most individuals recovering from an eating disorder strongly benefit from meeting with a dietician and it is important to be evaluated for medical causes and consequences of the eating disorder. Thus, eating disorder treatment often involves a treatment team including a dietician, the client s primary care physician, and a psychiatrist. If you are treated by another professional, I will coordinate my services with them. Athletes and individuals who are interested in incorporating exercise into their recovery are encouraged to work with a sport psychologist or personal trainer during treatment. Additionally, in order to provide the best possible services, I may, at times, consult with other mental health professionals.
3 What to Expect from Our Relationship As a professional, I will use my knowledge and skills to best help you. This includes following the standards of the American Psychological Association, or APA. In your best interests, the APA puts limits on the relationship between a therapist and a client, and I will abide by these. Let me explain these limits, so you will not think they are personal responses to you. First, I am licensed and trained to practice psychology not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints. Second, state laws and the rules of the APA require me to keep what you tell me confidential. You can trust me not to tell anyone else what you tell me, except in certain limited situations. I will explain what those are in the About Confidentiality section. Third, in your best interest, and following the APA s standards, I can only be your therapist. I cannot have any other role in your life. I cannot now, or ever, be a close friend to or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship. About Confidentiality Psychological services are only effectively provided in an atmosphere of trust. You expect me to be honest with you about your problems and progress. I expect you to be honest with me about your expectations for services, your compliance with treatment, and any barriers to treatment. I will treat with great care all the information you share with me. It is my ethical commitment, and your legal right, that information and records about our sessions be kept private. That is why I will ask you to sign a release of records form before I talk about you or send my records about you to anyone. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me without your signed consent. In all but a few rare situations, your confidentiality (your privacy) is protected by state law and by the rules of my profession. Here are the most common cases in which confidentiality is not protected: 1. If you were sent to me by a court for evaluation or treatment, the court expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court to know. You have a right to tell me only what you are comfortable having disclosed to the court. However, withholding information may be harmful to you. 2. If you are suing someone, being sued, or being charged with a crime and you tell the court that you are seeing me, I may then be ordered to show the court my records. Please consult your lawyer about these issues. 3. If I have reason to believe that you are a serious threat of harm to yourself or another person, the law requires me to take appropriate action to protect you or that other person. This usually means telling others about the threat. 4. If you tell me that you have abused or neglected (or intent to abuse or neglect) a minor child or incapacitated adult, or heard/observed abuse or neglect, I am legally required to report this to the authorities.
4 In order to provide the best quality care, I do consult with colleagues who are affiliates of Under the Umbrella. If I consult with colleagues and specialists about ongoing work, this pursuit of quality assurance never involves your name or any specifics through which you might be identified. Except for the situations I have described above, I will always maintain your privacy. If, while waiting for your appointment, you see another person leave this office, I ask that you not disclose their name or identity to anyone. If your records need to be seen by another professional, or anyone else, I will discuss it 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 any questions, please ask me. Generally, your health insurance company will receive the dates of our appointments, my charges, a diagnosis, and perhaps a brief treatment plan. It will become part of your permanent medical record. If you are concerned about this, please discuss it with me. As part of the cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and my treatment methods. I will let you know if this should occur and what the company has asked for. Please understand that I have no control over how these records are handled at the insurance company. My policy is to provide only as much information as the insurance company will need to pay your benefits. About Our Appointments The therapy process involves responsibility and commitment on the part of the clinician and the client. You will receive the most benefit if you attend your sessions regularly and participate actively in the therapy process. Please arrive on time for your appointments and make arrangements to stay for the duration of the session. If you arrive late for the session, we will only be able to meet for the originally scheduled time, and will not be able to extend the session. I request that you do not bring children with you if they are young and need babysitting or supervision, which I cannot provide. Appointments are typically once a week and last minutes. Once we decide to work together, I will try to reserve a regular appointment time for you into the foreseeable future. I will notify you several weeks in advance if I need to reschedule an appointment. Fees, Payments, and Billing You are responsible for payment at the time of services unless other arrangements have been made in advance. Payment for services is important in any professional relationship. My current therapy fee is $ for the initial 50-minute consultation session, and $ for each subsequent minute psychotherapy sessions. Please pay for each session in full (or provide your co-pay if you are using an insurance plan) at the end of the session. I accept cash and checks. There is a $20.00 returned check fee plus any bank charges. There may be other charges for additional time spent on your case. For example, telephone consultations, diagnostic testing, request for letters or documentation, etc. You will be made aware of such charges before they are incurred. I am currently a participating provider for Cigna. If you have a different type of insurance, I will supply you with an invoice for my services with the standard diagnostic and procedure codes for billing purposes, the times we met, my charges, and your payments. You can use this to apply for
5 reimbursement. You not your insurance company or any other person or company are responsible for paying the fees we agree upon. If you ask me to bill a separate person such as a spouse or relative, and I do not receive payment on time, I will then expect this payment from you. Except for serious emergencies or unforeseen health problems, you will be charged $60 for sessions cancelled with less than 24-hours notice. Your insurance provider will not reimburse you for these missed or canceled appointments. If it is possible, I will try to find another time to reschedule the appointment. If you think you may have trouble paying your therapy fee on time, please discuss this with me. If there is any problem with my charges, my billing, your insurance, or any other money-related point, please bring it to my attention. I will do the same with you. Such problems can interfere greatly with our work. They must be worked out openly and quickly. If You Need to Contact Me Because I do outpatient evaluation and therapy in a limited practice, I am not quickly accessible in between scheduled sessions. Since I do not have an on-call service and check messages only a couple of times a day, if you have an emergency or are in crisis, you should immediately go to the emergency room of your local hospital or call the area suicide prevention crisis line for assistance. Once your safety is assured, please call me and leave me a message letting me know what has occurred. For non-emergency situations, you may leave a message on my voice mail and I will return your call as soon as I can (usually within 24 hours). I find that telephone therapy does not work as well as faceto-face therapy, and so I discourage it and generally suggest that we discuss your concerns in our sessions when possible. Phone calls are typically reserved for changes in appointments. 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 testimony you require. This position is based on two reasons: 1) My statements will be seen as biased I your favor because we have a therapy relationship; and 2) the testimony might affect our therapy relationship, and I must put this relationship first. If, as part of our therapy, you create and provide to me records, notes, artworks, or any other document materials, I will return the originals to you at your written request but will retain copies. Statement of Principles and Complaint Procedures I fully abide by all the rules of the American Psychological Association (APA) and by those of my state license. Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with me at once. Our work together will be slower and harder if your concerns with me are not worked out. I will make every effort to hear any complaints you have and to seek solutions to them. If you feel that I, or any other therapist, has treated you unfairly or has broken a professional rule, please tell me. You can also contact the state or local
6 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 state board of psychologist examiners, the organization that licenses those of us in the independent practice of psychology. In my practice as a therapist, I do not discriminate against clients because of 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. I will always take steps 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. If I Need 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 write down the name and information of your chosen contact person in the blanks provided. Name: Phone: Address: Relationship to you: Our Agreement I, the client (or his or her parent or guardian), understand that I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement. I understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in the brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you. I understand that no specific promises have been made to me by this therapist about the result of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective. Additionally, please note that the clinicians that are sharing this office space practice independently. I have read, or have had read to me, the issues and points in this brochure. I have discussed those points I did not understand, and have had my questions fully answered. I agree to act according to the points covered in this brochure. I hereby agree to enter into therapy with Christy Duffy, PhD, HSPP, and to cooperate fully and to the best of my ability, as shown by my signature here.
7 Signature of client (or person acting for client) Date Printed name Relationship to client: Self Parent Legal guardian Health care custodial parent of a minor (less than 14 years of age) Other person authorized to act on behalf of the client specify I, the therapist, have met with this client (and/or his or her parent or guardian) for a suitable period of time, and have informed her or him of the issues and points raised in this brochure. I have responded to all of his or her questions. I believe this person fully understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my signature here. Kate Miller, PsyD, HSPP Date Copy accepted by client Copy kept by therapist
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
Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835 Professional Policies and Consent to Treatment Welcome to my practice. I appreciate your giving me the
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
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
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
Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108 COUNSELOR-CLIENT SERVICE AGREEMENT Welcome to my practice. This document
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
Life Tide Counseling, PC Individual, Marriage and Family Counseling OUTPATIENT SERVICES CONTRACT Therapist: ( Therapist ) Client: ( Client ) Welcome to Life Tide Counseling, PC ( Life Tide Counseling ).
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
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
Jennifer L. Trotter, Ph.D. Telephone: 248-880-4966 - Email: JenniferLTrotter@gmail.com Licensed Clinical Psychologist Address: 25882 Orchard Lake Road - Suite L-4 - Farmington Hills, MI 48336 OUTPATIENT
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
PSYCHOLOGY 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
Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional
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
Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents PATIENT INFORMATION BROCHURE, CONTRACT & CONSENT FORM PSYCHOLOGICAL
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
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
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
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.
Deborah Issokson, Psy.D. Licensed Psychologist HEALTHCARE PRIVACY AND SECURITY POLICIES PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important
The Bethesda Group Psychological Services, LLC Old Georgetown Office Park 7988 Old Georgetown Road, 8A Bethesda, Maryland 20814 Phone 301.718.4544 Fax 301.718.4545 email@example.com PSYCHOTHERAPIST-PATIENT
RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043 1 PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) Welcome to my practice. This agreement contains important information
Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents PATIENT INFORMATION BROCHURE, CONTRACT & CONSENT FORM PSYCHOLOGICAL
Dr. Rebecca I. Howard, PsyD 609 W. Littleton Blvd, Ste 303, Littleton, CO 80120 303 730 8083 firstname.lastname@example.org CLIENT INFORMATION AND CONSENT Welcome to my practice. This document contains important
J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax email@example.com www.jgarydolinskyphd.com Psychologist-Patient
TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Minor Consent for Treatment and Service Agreement Welcome to Tidelands Counseling!
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
Gay Galleher, Ph.D., A.B.P.P. Board Certified in Clinical Psychology Mailing: 10 State Road, Suite 9, Bath, Maine 04530 Office: 579 Berry s Mill Road, West Bath, Maine 04530 207-443-1016 OUTPATIENT SERVICES
ANA I. AGUIRRE-DEANDREIS, Ph.D. Clinical Psychologist 6325 Executive Boulevard, Rockville, Maryland 20852 Tel:(301)571-2324 Fax:(301)770-0276 INFORMED CONSENT FOR TREATMENT This document contains important
Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 PSYCHOLOGIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement)
TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Adult Consent for Treatment and Service Agreement Welcome to Tidelands Counseling! Tidelands
San Diego Psychotherapy, Inc. Shoshana Shea, Ph.D. Licensed Psychologist #PSY19888 3821 Front Street San Diego, CA 92103 tel. (619) 269-2377 fax (619) 294-3225 www.shoshanashea.com OFFICE POLICIES, AGREEMENT
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:
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
THRIVE Center for ADHD and Comprehensive Mental Health Informed Consent and Clinical Policies Welcome to THRIVE. This document contains important information about our professional services and business
: 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:
Tampa Psychology Brian Nussbaum, Psy.D. Licensed Clinical Psychologist, FL license# PY6830 27446 Cashford Circle #101 Wesley Chapel, FL 33544 (813) 545-7754 Welcome to my practice. This document contains
OUTPATIENT 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
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
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:
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary
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
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:
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
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
OUTPATIENT SERVICES CONTRACT Welcome to Urban Wellness. Since this is your first visit, we hope what is written here can answer some of your questions as you seek therapy. Please let us know if you want
JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT This document contains important information about my professional and business policies. It also
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
Alison J. Bomba, Psy.D. Licensed Psychologist OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please
Helen G. Jenne, Psy.D.,FAACP Board Certified, Clinical Psychology PSYCHOLOGIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional
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.
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
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
Bert Epstein, Psy.D. 159 Kentucky Street Suite 3 Petaluma, CA 94952 707 242-1989 firstname.lastname@example.org CA License PSY 21404 Office Policies & Agreement for Psychotherapy Services Welcome. Your first visit
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
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
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.
OUTPATIENT SERVICES CONTRACT and DISCLOSURE STATEMENT Welcome to Northwest Neurobehavioral Institute (NNI). This document contains important information about our professional services and business policies.
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
A PSYCHOLOGICAL SERVICE DR. PAMELA REBECK PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT AND INFORMED CONSENT Welcome to my practice. This document (the Agreement) contains important information about my professional
Michael S. McLane, Psy.D. Licensed Psychologist 12830 Hillcrest Road Suite D233 Dallas, TX 75230 Ph: (972) 620-1225 Fax: (972) 620-4393 Informed Consent to Treatment / Evaluation I,, who was born on and
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
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.
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,
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:
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
Psychotherapy Services Agreement with Angel Onley-Livingston Notice of Policies and Practices to Protect the Privacy of your Health Information This document contains important information about our professional
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
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
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
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.
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
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
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.,
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
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
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