PROFESSIONAL DISCLOSURE STATEMENT. Informed Consent

Transcription

1 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas PROFESSIONAL DISCLOSURE STATEMENT Qualifications: Elissa is a Licensed Professional Counselor Intern under the supervision of Patti Doumany, a Licensed Professional Counselor Supervisor and Registered Play Therapist Supervisor. Elissa received her Masters of Science in Counseling Psychology from Southern Methodist University where she gained knowledge and working experience in group, individual, adolescent, activity, and play therapy. She passed her licensing exam in 2010 and holds an intern status until she completes three-thousand client hours. Experience: Elissa is most passionate about working with adolescents, children, and their parents. In her graduate studies and under supervision, she primarily worked with children from age three to ten using play and activity therapy. During the last two years of her Masters program, she worked as a Parent Educator for the Dallas Association for Parent Education (DAPE) where she taught Positive Parenting curriculum over child development, language, motor and social skills, appropriate verbal interactions, communication and positive discipline techniques. Elissa also holds a position in a psychiatric hospital where she provides counseling to adolescents, children, and adults in a group setting. Nature of Counseling: It is my theoretical belief that each person is the sum of all his or her combined life experiences and that these experiences shape a personal view of self, others, and the world. Either consciously or subconsciously our actions, choices, and behaviors stem from our subjective understanding of what is true, comfortable, and often safe. When we have contradictory or off-putting experiences we may find ourselves in patterns and/or negative cycles of behavior that hinder personal growth. Together we will process relevant and meaningful life experiences and belief systems in order to increase insight and self-understanding. A number of therapeutic strategies may be used during our time together. These include but are not limited to processing emotions, discussion of early childhood experiences, evaluating and reassessing thought patterns, psycho-education, and/or role-play. Informed Consent Emergency/Crisis: Please know that Crossroads Child & Family Counseling, PLLC does not provide a 24-hour crisis counseling service. Should you experience an emergency necessitating immediate mental health attention, call or go to the nearest emergency room for assistance. Counseling Relationship: During the course of counseling, you and/or your child will meet with Elissa for approximately 45 minute sessions. Although sessions may be psychologically intimate, the relationship between client and therapist is professional. Please do not ask me to relate to you in any way other than the professional context of counseling sessions. counseling sessions. Effects of Counseling: At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discounting counseling. While benefits are expected from counseling, specific results are not guaranteed. Counseling is a process of personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Some of these life changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achieve the best possible results for you. v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 1

2 Clients Rights Some clients need only a few counseling sessions to achieve their goals; others may require months or even years. As a client, you are in complete control and may end our counseling relationship at any time, though I do ask that you participate in a termination session. You also have the right to refuse or discuss modification of any counseling techniques or suggestions that you believe might be harmful. You are assured that counseling services will be rendered in a professional manner consistent with accepted legal and ethical standards as stipulated by the Texas State Board of Examiners of Licensed Professional Counselors and the HIPAA security and privacy rules. If at any time, for any reason you are dissatisfied with the services at Crossroad Child & Family Counseling PLLC, please let me know so that existing issues can be worked through. If someone is not available to resolve your concerns, you may report your complaint. Referrals: Should you and/or Elissa believe that a referral is needed; you will be provided with some alternatives, including programs and/or people who may be available to assist you. Also, should you miss two appointments concurrently for whatever reason; a referral will also be provided. You will be responsible for contacting and evaluating those referrals and/or alternatives. Fees: In return for a fee of $75 per session, agrees to provide counseling services for you. The original intake session is $ The fee for each session will be due at the conclusion of each session. The rate for all related counseling services, including but not limited to, time incurred due to phone calls over 5 minutes, medical concerns, psychiatric concerns, home and family social studies, child protective service cases, adoption and foster care, issues of divorce, child custody, attorney consultations, educational concerns, behavioral concerns, ARD meetings, classroom observations, interactions with insurance providers, etc., will be billed at $75 per hour in 15 minute increments. In the case of off-site services, fee includes travel time to and from. Checks are payable to, ". CANCELLATION POLICY: In the event you are unable to keep an appointment, please give notification of 24 hours or more. IF A CANCELLATION OCCURS WITHOUT A 24 HOUR NOTICE OR YOU FAIL TO KEEP YOUR SCHEDULED APPOINTMENT, A REGULAR SESSION FEE WILL BE BILLED TO YOU. All returned checks will incur a $25.00 return-check fee. If you are absent two weeks in a row without contacting me, you will be provided with other referral sources for further counseling. Likewise, if you are absent three sessions in a row, even with contact, you will provided with other referral sources for a continuation of counseling at a different facility. If you do, at any time, intend to discontinue counseling, please inform me as soon as possible so that other clients can be serviced. Records and Confidentiality: All of our communications become part of the clinical record. Records are the property of. Adult client records are disposed of six years after the file is closed. Minor client records are disposed of six years after the client's 18th birthday. Guardians Most of our communication is confidential, but the following limitations and exceptions due exist: a) you are a danger to yourself or someone else; b) you disclose sexual contact with another mental health professional; c) I am ordered by a court to disclose information; d) you direct me to release your records; e) there is reason to believe that abuse or neglect of a child, elderly, or disabled person occurred or a situation exists possibly leading to abuse or neglect; or, f) I am otherwise required by law to disclose information. Should you or an entity through your signature, request a copy of you or your child s counseling records, please be aware that a $30.00 record preparation fee will be incurred and a Release of Records form must be signed. An overall counseling summary, in lieu of records, may also be provided. A fee of $30 per 15 minutes is charged for preparation time. If records are subpoenaed, this does not indicate an automatic release of records and is at liberty to be quashed should it be deemed not in the client s best interest. To further protect your Confidentiality, if I see you in public, I will only acknowledge you if you approach me first. v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 2

3 Court: It is in your best interest to know that conducting expert witness/testimonial service is not in my area of interest or expertise. I do not agree to serve as an expert witness or to provide testimonial services for you, and you agree not to cause my services to be used in this way. If you are seeking counseling for court or court-related purposes or motivations, I will provide you with alternative appropriate referral sources. Should you, your attorney, your spouse or ex-spouses attorney,subpoena me or your client file as a factual case witness, or involve me in courtrelated proceedings, you agree to pay $ for every hour of my time involved, including case preparation, travel, witness time, and any wait time related to a court-related process. You further agree to pay a retainer fee of $2, at the time a subpoena is served, to be applied toward these charges. If a subpoena is issued for me, it will be turned over to an attorney, and I will consult with an attorney as necessary at your expense. A bill will be rendered to you for immediate payment when a subpoena is issued. You further agree that if my supervisor is required to participate in court-related proceedings, you will be assessed her court fees as well. If you have a suspicion that your case will be going to court, or you will need therapist testimony, please let me know before a counseling relationship is established, and appropriate referral sources will be provided to you. Please note: 24 hour advanced notice is required if a cancellation occurs related to a court process, including dismissal of case. If a 24 hour notification is not made, a fee of $2,400 will be billed. (8 $300 per hour) Child Counseling/Play Therapy Play Therapy Logistics: If a divorce has occurred, a copy of the section in the divorce decree addressing custody, rights to medical and psychological treatment, along with the first page and signature page of the decree is required. If joint custody exists, the parent not bringing the child will also be contacted at some point, via letter, with an invitation for that parent to participate in the counseling process. Please understand that the other parent will only be contacted to assist the therapist in the manner of working with your child. The therapist is not to provide information to the other parent regarding your child other than under the auspice of the therapist's work with the child within the counseling session. Furthermore, it is helpful that the therapist is apprised of other existing important documentation, such as court orders, mental health evaluations, etc. For play therapy, sometimes it may be necessary to end the session early depending upon the following circumstances: the nature of the cleanliness of the playroom, the child s ability to leave when the session is over, a situation where play therapy could no longer continue (e.g., child gets sick, child breaks several toys, child chooses to leave and not return, etc.), and the need for a parent consultation. Because the session may need to end early at times, please be sure to remain in the waiting room for most of the session. If you choose to leave the waiting area, please notify Elissa Hargrove before the session begins. Children in the playroom are not asked to clean the room following the session. The reason for this is as follows: If play is a child s language and toys are the child s words; having a child clean up the play room following the session would be analogous to asking the child to clean up his/her emotional world. It would be similar to having an adult take back everything he/she said at the end of the counseling session. This is a unique stipulation to play therapy. Please know we are not advocating this action for other circumstances only play therapy. When the child greets you in the waiting room following the counseling session, it is best not to ask questions, such as Did you have fun? While playing is a natural, pleasurable activity for the child, children in play therapy are involved in playing out problems and emotional struggle and, therefore, at times playing may not be so enjoyable. Furthermore, when asked what the child did in play therapy, the child will typically respond, I played. This would be similar to asking an adult in counseling what he or she did in the session We talked. Before your child attends play therapy, please take him/her to the bathroom. Play therapy can often be very emotional freeing, causing the child sometimes to have to use the bathroom during therapy. It is helpful if the child goes to the restroom before the session begins. Also, if your child is coming from school and is hungry, please give him/her a snack before therapy starts. Only in rare circumstances will food be provided for a child in play therapy. In such a situation, this will be discussed with the caregiver and added to the treatment plan. Please know that the playroom has a variety of media that can be messy (e.g., easel paints, water-color paints, Play-Doh, clay, water, sand, etc.). Please dress your child in clothes that can tolerate mess or possible stains should the child spill paint on him/her. Also, if your child is allergic to any substance that falls into this realm, it is your responsibility to let the play therapist know so that appropriate modifications can be made for your child. v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 3

4 Parental Involvement: Parental involvement is crucial when counseling children. Elissa will meet with you on a regular basis to exchange feedback concerning your child. Most situations require a parent to schedule a parent consultation or family session about every four weeks. (Regular session fees apply.) To better facilitate the play therapy process, a Weekly Child Report form is to be completed and brought to each session. Please make several copies of this form. If you have a specific question or concern that cannot wait until your next parent consultation, please include your question on the Weekly Report Form and Elissa will respond as soon as possible. Feedback provided to parents/guardians will include overall play themes for your child. To protect the child s confidentiality and ensure a therapeutic alliance with your child, discussion on specific play behaviors will not be discussed. However, most certainly at times, it will be necessary to discuss specific play behaviors and what this may mean for your child By my signature below, I acknowledge reading and understanding this document, and that any questions I had about this document were answered to my satisfaction, and that I was furnished a copy of this document. My signature below acknowledges my commitment to comply with all its terms and requirements, issue consent for Elissa Hargrove, MS, LPC-Intern to work with me and my child, understand and agree to my financial obligations including the cancellation policy stated above, and acknowledge my commitment to conform to its entire specifications. Client / Guardian Signature Counselor Signature Updated Sept 2011 Client Copy v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 4

5 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas Professional Disclosure Statement Agreement By my signature below, I acknowledge reading and understanding this document, and that any questions I had about this document were answered to my satisfaction, and that I was furnished a copy of this document. My signature below acknowledges my commitment to comply with all its terms and requirements, issue consent for Elissa Hargrove, MS, LPC-Intern to work with me and my child, understand and agree to my financial obligations including the cancellation policy stated above, and acknowledge my commitment to conform to its entire specifications. Client / Guardian Signature Counselor Signature Updated Sept 2011 Counselor Copy v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 5

6 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas CONFIDENTIALITY & CONSENT FOR SERVICES This agency holds your confidentially in the highest regard, from your identity to the information you offer in session. All client information is protected under both state and federal confidentiality laws. Specific information pertaining to your case will not be released to anyone except for specific billing purposes, your request for a release, situations involving risk to harm (see below), or court orders relating to a criminal case or investigation. There are certain limitations to confidentiality, some of which are required by law and others are required by the professional ethical code. Please be aware of the following exceptions to privileged communications: 1. Any evidence or reason to believe that a situation of child, elderly or handicap abuse and/or neglect exists. By law, this information must be reported to the Texas Department of Protective and Regulatory Services. 2. Any probability of physical harm to yourself or others. Protection form physical injury takes precedence over confidentiality and the therapist's primary responsibility is his/her "duty to warn" if she/he believes someone to be in imminent, physical danger. Therefore, if an individual intends to take harmful, dangerous, or criminal action against self or another, it is the therapist's duty to report such action or intent to the authorities. 3. If subpoenaed by a court, this may involve providing the court with verbal testimony and/or records such as clinical notes, tapes, letters, testing, and ledgers. 4. If a third-party billable service is paying or reimbursing for counseling services, it may be necessary to provide the billable party with counseling diagnoses, nature, and progress. 5. If client discloses that they have a disease commonly known to be both communicable and life threatening, counselors may be justified in disclosing information to identifiable third parties, if they are known to be at demonstrable and high risk of contracting the disease. I (we) do hereby give my (our) consent for counseling and/or related services at this facility. I (we) understand that all information pertaining to my (our) services all remain completely confidential except in those cases where confidentiality is limited. These limits of confidentially, as prescribed by Texas law, have been explained to me. I (we) further understand that any release of information concerning my (our) services shall occur only with my (our) written consent, excluding the above stipulated exceptions. Client Signature _: I affirm that I am the legal guardian of and here by grant permission for my child to participate in counseling services with this agency. If there is shared custody, I will provide this therapist with a copy of the divorce decree and know that the other guardian can also have access to my child's records. Parent/Guardian Signature v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 6

7 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas COURT TESTIMONY AGREEMENT I am seeking counseling for court testimony or court involvement on behalf of Elissa Hargrove, MS, LPC-Intern for myself, my child, or a family member. I am NOT seeking counseling for court testimony or court involvement on behalf of Elissa Hargrove, MS, LPC-Intern for myself, my child, or a family member. Court: It is in your best interest to know that conducting expert witness/testimonial service is not in my area of interest or expertise. I do not agree to serve as an expert witness or to provide testimonial services for you, your child, or any member of your family, and you agree not to cause my services to be used in this way. If you are seeking counseling for court or court-related purposes or motivations, I will provide you with alternative appropriate referral sources. Should you, your attorney, your spouse or ex-spouses attorney,subpoena me or your client file as a factual case witness, or involve me in court-related proceedings, you agree to pay $ for every hour of my time involved, including case preparation, travel, witness time, and any wait time related to a court-related process. You further agree to pay a retainer fee of $2, at the time a subpoena is served, to be applied toward these charges. If a subpoena is issued for me, it will be turned over to an attorney, and I will consult with an attorney as necessary at your expense. A bill will be rendered to you for immediate payment when a subpoena is issued. You further agree that if my supervisor is required to participate in court-related proceedings, you will be assessed her court fees as well. If you have a suspicion that your case will be going to court, or you will need therapist testimony, please let me know before a counseling relationship is established, and appropriate referral sources will be provided to you. Please note: 24 hour advanced notice is required if a cancellation occurs related to a court process, including dismissal of case. If a 24 hour notification is not made, a fee of $2,400 will be billed. (8 $300 per hour) By your signature below, you are indicating that you read and understood this document, that you are in full agreement with the contents of this document, and that any questions you had about this document were answered to your satisfaction. Client / Guardian Signature Counselor Signature v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 7

8 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas CONSENT FOR DISCLOSURE OF INFORMATION I,, hereby provide authorization for Elissa Hargrove, MS, LPC-Intern, to obtain and /or provide the following information: To/from the following parties/agencies: Agency Name Elissa Hargrove, MS, LPC-Intern Contact Name 3550 Parkwood Blvd. Suite 401 Address Frisco, TX City, State, Zip Code Client / Guardian Signature Counselor Signature v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 8

9 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas CONSENT FOR DISCLOSURE OF INFORMATION I, hereby provide authorization for Elissa Hargrove, MS, LPC-Intern, to obtain and/or provide the following information concerning: (child s name) (child s date of birth) Consultation with school personnel regarding academic, social, behavioral, and mental health observations. Special Education Records Discipline Records To / From The following parties/agencies: To / From School Name Contact Name Address City, State, Zip Code Fax # Phone # Elissa Hargrove, MS, LPC-Intern Patti Doumany, Med, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, TX Client / Guardian Signature Counselor Signature v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 9

10 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas Informed Consent to Videotape - Parent My signature below confirms that conditions of my consent to be videotaped have been explained to me, and I understand the following: My child is not required to be videotaped and I am under no obligation to have this session recorded. I can withdraw my permission at any time during or after the session. My access or my child s access to counseling services will not be affected by my decision not to consent to videotaping. I understand viewing of the tape is for the sole purpose of professional development, supervision, and/or training. Only my child s first name will be used, or will not be mentioned; the contents of the tape will remain confidential within the educational, training or supervision site. The tape will be erased or destroyed upon completion of the professional development, supervisory and/or training review of this session. I may revoke this videotaping consent at any time by submitting to Elissa Hargrove, MS, LPC-Intern a request to withdraw my permission. The original copy of this consent form will be kept in my child s records with Crossroads Counseling. Client / Guardian Signature Counselor Signature v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 10

11 HIPPA 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. This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that is related to your past, present, or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health insurance may be used and disclosed by your therapist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the therapist s practice as necessary, and any other use required by law. Treatment: We will use and disclose your protected health information as necessary to provide, coordinate, or manage your health care and any related services. This includes the coordination of management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you; or your protected health information may be provided to a physician to whom you have referred to insure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay or a higher level of treatment may require that your relevant protected health information be disclosed to the health plan to obtain approval for admission. Healthcare Operations: We may use or disclose as needed, your protected health information to support the business activities of your therapist s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of therapists associated with this practice, licensing, marketing and fund raising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to graduate students and Licensed Professional Counselor Interns who see clients at our office. In addition, we may call you by name in the waiting room when the therapist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization: communicable diseases, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, and if you present a threat to yourself or to others. Other permitted and required uses and disclosures will be made only with your consent, authorization and opportunity to object, unless required by law. You may revoke this authorization in writing at any time, except to the extent that your therapist of therapist s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Acknowledgement of Receipt of HIPPA Notice of Privacy Practices for this office: Client signature (parent/guardian if minor patient) Consent for Use and Disclosure of Health Information: I hereby permit and release Elissa Hargrove, MS, LPC-Intern to release and furnish all medical and financial date related to my care that may be necessary now or in the future for purposes of treatment, payment, or healthcare operations to assist with, aid in, or facilitate the collection of data for purposes of utilization review, quality assurance, or medical outcomes evaluation purposes. Such information may be released to HMOs, PPOs, managed care organizations, IPAs, or other governmental or third party payors, or any organization contracting with any of the above entities to perform such functions. Client signature (parent/guardian if minor patient) You have the right to request restrictions of uses on disclosure of your health information; however, this office is not required to agree to a requested restriction. You have the right to revoke this consent in writing, except to the extent that this office has previously taken action in reliance on this consent. Your treatment by this office is conditional on your signing this consent. v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 11

12 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas GENERAL INTAKE INFORMATION Today s : Child s Name: Guardian(s): (Who child is living with Referred by: Child s date of birth: Age: Gender: M F Home Address: street city zip Preferred guardian contact: Home Phone #: Cell Phone: Work Phone: May we contact you at Work? Y N May we leave you a message? Home phone: Cell phone: Work phone: address: Emergency Contact: ph# (Signature at end of document indicates consent to contact this person in the rare case an emergency should occur) School child is attending: Grade: Main Teacher: Current School Grades: Is your child receiving special education or other special services at school? Y N If yes, please explain. v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 12

13 of Last Physical: Primary Care Physician: Current diagnosis or medical concerns: Please list all current medications: Did your child experience any developmental delays in the following areas? (circle) Physical: N Y Speech: N Y Social: N Y Emotional: N Y Briefly describe why you are seeking counseling for your child: How would you rate the intensity of the problem or concern? (1 = NOT intense.10 = VERY intense) Past Counseling History: Length of Service Agency and Therapist Providing Service Child s current household: Natural parents Father only Mother only Adoptive parents Relatives Foster family Natural father and stepmother Natural mother and stepfather Other Primary Household (anyone currently living with child) Name Age Gender Relationship v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 13

14 Who in your family is your child closest to? Most distant from? In most conflict with? Does your child sleep in his/her own bed? Y N Please describe your child s sleeping patterns, bedtime behaviors: Please describe your child eating habits: Does your child exhibit any fears? Y N If yes, please describe: Has your child had any behavioral or emotional difficulties? (Even if they are no longer affecting him/her) Y N If yes, please describe: Has your child ever experienced any traumatic situations? Y N If yes, please explain: Has your child ever talked about hurting or killing himself/herself or another person? Please describe: Has your child ever used or abused medication, illegal drugs, or alcohol? Y N Please check and describe any past, present, or anticipated circumstances in your family. Divorce Serious illness Legal problems Relocations Psychiatric disorders Eating disorders v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 14

15 Physical/sexual abuse Attempted/completed suicide Alcohol/drug abuse Grief or significant loss Depression ADHD/ADD Other Helpful Information: INFORMATION ON CHILD S MOTHER First Name MI Last biological mother stepmother adopted mother of birth Occupation Work days and hours Would you describe your work as stressful? Y N Religious background: Spiritual beliefs: History of learning, emotional, or behavioral problems? Y N (If yes, please explain) History of alcohol/drug/substance abuse? Y N (If yes, please explain) v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 15

16 Current living arrangements: Family of origin Relatives Single Married Roommate/Significant other(s) Marital Status History (include all that apply and duration of each) Never married Married to Separated to Divorced Widowed Married to Separated to Divorced Widowed Did you have experiences that felt overwhelming or traumatizing in our life, during childhood or beyond? (please describe) Please tell about any losses or deaths in your family: Do any of these experiences come to your mind regularly now? Who are your major resources of support now? INFORMATION ON CHILD S FATHER First Name MI Last biological father stepfather adopted father of birth Occupation Work days and hours Would you describe your work as stressful? Y N Religious background: Spiritual beliefs: History of learning, emotional, or behavioral problems? Y N (If yes, please explain) History of alcohol/drug/substance abuse? Y N (If yes, please explain) v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 16

17 Current living arrangements: Family of origin Relatives Single Married Roommate/Significant other(s) Marital Status History (include all that apply and duration of each) Never married Married to Separated to Divorced Widowed Married to Separated to Divorced Widowed Did you have experiences that felt overwhelming or traumatizing in our life, during childhood or beyond? (please describe) Please tell about any losses or deaths in your family: Do any of these experiences come to your mind regularly now? Who are your major resources of support now? General Intake Form completed by: Parent/Guardian Signature : Parent/Guardian Signature : v PLLC 3550 Parkwood Blvd. Suite 401v Frisco, TX Page 17

18 Elissa Hargrove, MS, LPC-Intern Patti Doumany, MEd, LPC-S, RPT-S 3550 Parkwood Blvd. Suite 401 Frisco, Texas WEEKLY REPORT 1. Week Rating of Behavior (1 = NOT stressful compared to last week: 10=VERY stressful compared to last week) Reason(s) for choosing the number above (i.e., specific behaviors that occurred) 3. Any new changes/happenings this week (i.e., can be small changes for your child, such as he/she had a sore throat, a parent worked longer hours this week or can be significant changes for your child, such as a pet dying, car wreck, etc.) 4. New Behaviors Noticed: 5. Medication: Not Applicable No Change Change: 6. Something positive your child did this week that either surprised you or impressed you: 7. Other Concerns or Questions?