Client s Name (First/Middle/Last) extraordinarylife Counseling & Coaching Client Intake Information Address: City State ZIP Sex: M F Age of Birth / / Driver s License or ID # State Marital Status: Single Married Separated Divorce Common-Law Marriage Widow No. times Married of current Marriage / / Separation / / Divorce / / Death of spouse / / Place of Employment: Occupation: Yearly Gross Income: Phone Numbers/e-mail (only include those that we have permission to call or leave a voice/email message): Home Work Cell Personal E-mail Work E-mail Spouse Fiancé Parent or Guardian (required if client is a minor or if also plan to receive counseling) Name (if applicable) Address: City State ZIP Sex: M F Age of Birth / / Driver s License or ID # State Marital Status: Single Married Separated Divorce Common-Law Marriage Widow No. times Married of current Marriage / / Separation / / Divorce / / Death of spouse / / Place of Employment: Occupation: Yearly Gross Income: Phone Numbers/e-mail (only include those that we have permission to call or leave a voice/email message): Home Work Cell Personal E-mail Work E-mail Spouse Fiancé Parent or Guardian (required if client is a minor or if also plan to receive counseling) Name (if applicable) Address: City State ZIP Sex: M F Age of Birth / / Driver s License or ID # State Marital Status: Single Married Separated Divorce Common-Law Marriage Widow No. times Married of current Marriage / / Separation / / Divorce / / Death of spouse / / Place of Employment: Occupation: Yearly Gross Income: Phone Numbers/e-mail (only include those that we have permission to call or leave a voice/email message): Home Work Cell Personal E-mail Work E-mail Religious Orientation How did you hear about extraordinarylife? Briefly state your reason for seeking counseling. Church Affiliation Family Members living at home First and Last Name(s) Age Relationship to client Page 1 of 7
Legal Authorization to Provide Child with Emotional Counseling (If applicable for ages 17 and under) As parent/guardian do you have Legal Authorization to provide this child with emotional treatment? Yes No Explain: If not, do you have written authorization from such parent/guardian to provide this child with emotional treatment while in your care? Yes or No Explain: Parent/Child Confidentiality Statement As therapists, we respect your right as a parent to gain access to all information included in the emotional care of your child. However, we believe that in the best interest of the therapeutic relationship, confidentiality should be maintained between your child and the therapist, except in the following cases: When child abuse is suspected When the child poses a clear and imminent danger either to self or another person When the therapist believes it is in the best interest of the child to disclose information to the parent Given the above, we request your permission to maintain a confidential relationship with your child. If you understand and agree, please provide your signature below. Print Client (Child) Name Print Parent/Guardian Name Signature Print Parent/Guardian Name Signature Print Counselor s Name Signature Parent/Guardian Comments: Additional Concerns: Page 2 of 7
Medical/Health Information: Personal Physician: Phone # of last visit: Results: of last physical: Results: Major illnesses/conditions Medications or treatments you are currently taking (list additional on backside of form): 1. 2. 3. 4. Previous Counseling? YES or NO If YES, : With whom: Reason: Outcome: In Case of emergency call AM Phone # PM Phone # Relationship The undersigned authorizes the release of all client information by the therapist for the purpose of review with client s physician if necessary, and/or for third party payers (when applicable). Such disclosures are limited to information that is reasonably necessary for treatment planning and/or payment. Signature of Client (if applicable) (if applicable) Communications I hereby authorize extraordinarylife and/or my therapist to communicate with me through: (please where applicable) Personal e-mail address Work e-mail address I prefer a voice mail message left on my: home phone work phone cell phone Please list any Family or Friend(s) that extraordinarylife may release medical/billing information to in case of emergency/debt collection Phone #_ Phone #_ Signature of Client Page 3 of 7
Policies and Procedures The following information is provided to acquaint you with the policies and procedures of extraordinarylife. If you have any questions about this information, please feel free to discuss them with your therapist or coach. Please initial each policy item.* It is your responsibility to read and adhere to these policies. 1. Sliding Fee Scale for Subsequent Sessions:* Counseling Session Fee is to be paid following each session and no later than same day. A flat fee of $110.00 will be charged for the Initial Evaluation/Counseling Session for an Individual, and $120 for a Couple or Family. Subsequent Counseling Sessions will be charged on a Sliding Fee Scale based on the client or responsible party s current Combined Family Gross Annual Income. Couples and family rates will increase by $30. To determine your counseling rate, use the Sliding Fee Scale below and the check box that best describes your current Combined Family Gross Annual Income. Please check your current Combined Family Gross Annual Income: Less than $65,999: fee is $80.00 per 45 minute session (couple & family rate: $110) $66,000 to $94,999 fee is $120.00 per 45 minute session (couple & family rate: $150) $95,000 to upward: fee is $160.00 per 45 minute session (couple & family rate: $190) Your home or office counseling/coaching - fees will be discussed upon scheduling of appointment. 2. Payment Adjustments:* / Approved Discount per 45min Session On an as-needed-basis, payment adjustments are available when the fee noted on our sliding fee scale may be too difficult for the client to meet; privilege not to be abused. If extraordinarylife agrees to lower the fees in order for the client(s) to complete their therapeutic plan, client(s) is then liable for the discounted difference if they choose to quit their program before completion. Program package(s), discounted session fees, and home visits will be discussed and agreed upon at end of the initial session. 3. Credit Card Payment Information:* Name on Card: Exp. : Card Number: Security Code: Signature: Credit Card Type: Visa MasterCard I hereby authorize extraordinarylife to charge my card for services rendered and/or missed appointments without notice 5. 4. 45 minute Sessions (+ additional charges in 15 minute increments thereafter):* Counseling fees noted above are based on a 45 minute session. We make it a goal to start and end on time. If you or your therapist deems it necessary to extend the session over 45 minutes, you will be charged in 15 minute increments thereafter (i.e., $80/45min session = $1.77per minute x a total of 60 minutes = $106.66; $120/45min rate =$2.66 per min. x a total of 60 min = $159.99; $160 rate = $3.55 per minute x a total of 60 minutes=$216.33, etc.) This increase applies to office, phone, skype, lengthy emails and/or texts conversations, and home visits based on the agreed upon fees. 5. 48-hour Advance Notice of Cancellation of Appointments:* If you need to cancel or reschedule an appointment please give a 48 hour advance notice. Failure to give proper notice or failure to show up for your scheduled appointment will result in the full charge of that scheduled appointment. Proper notice enables extraordinarylife to give someone else an opportunity to come in, or respond to other emergency cases. Your consideration to this matter is greatly appreciated. Exceptions will be made in unavoidable situations such as emergencies (i.e., illness, accidents, or death in the family). Whenever possible, extraordinarylife gives clients an opportunity to reschedule their cancelled appointment within the same week, however charges will be made on the day of the originally scheduled appointment (rescheduled appointment within the same week will not be charged a second time). I hereby authorize extraordinarylife to charge my credit card for missed appointments where I failed to give a proper 48hr notice 3. 6. $45 for Return Check Policy:* If a check is issued for payment and it is returned due to Non-Sufficient Funds (NSF) or other reasons, a $45 fee will be charged along with the session fee to be paid in cash or money order. Once a client issues a check that is returned, cash payments will be required for a period of 60 days after which time client can resume check payments if approved by counselor. Couples and Family Counseling:* 7. Couples and families seeking marriage counseling and/or family therapy may encounter times when the therapist may require individual sessions with some or all members in addition to the couple and/or family sessions. Our goal is to help you work through the issues at hand. extraordinarylife looks forward to working with you and your partner/family. Page 4 of 7
8. 911 Emergency Calls:* Call 911 in case of a serious emergency. To contact extraordinarylife in case of a therapeutic crisis or minor emergency, call our on-call cell phone number (281)441-9703. If no one is available to answer your call, please leave a message stating your name, phone number, and emergency and someone will call you as soon possible. Please make sure that the nature of your call is a real emergency if you leave this type of message (i.e. in a genuine crisis). If your life is in immediate danger, call 911. 9. Caller ID Issues:* There are times when your therapist/coach may need to return your call from their home or non-office phone. If your home phone is blocked to anonymous callers, you will need to unblock that service by dialing *87 on your phone. Your therapist/coach may keep their home number blocked for outgoing calls to their clients and will be unable to reach you otherwise. You can block your anonymous call blocking after their call by dialing *77. Further, if your therapist/coach s home number is shown on your Caller ID, please DO NOT return calls to that number. Instead, please call the number provided by your therapist/coach as their call-back number. 10. Therapist-Client Relationship:* It is very important that you have a good level of comfort and trust with your therapist. Your sense of well-being and your therapist level of efficiency in treating you depend on this. We recognize that in some cases this may not happen. Some clients and some therapists just don t make a good fit. If you should significantly disagree or feel uncomfortable with your therapist s clinical decisions please let them know and also feel free to discontinue your therapist-client relationship. In turn, your therapist/coach also reserves the right to end a therapist-client relationship in situations where there has been client non-compliance with treatment or payment of services. Your therapist will inform you to seek counseling elsewhere. 11. Confidentiality:* Concerning confidentiality, what is said in the room, stays in the room with a few exceptions. If client/parent/guardian share with therapist that they or someone else is in danger, because of legal precedent and law, the therapist will break confidentiality to help ensure safety. In the case of children clients, the therapist may share some general comments about the child s therapy sessions that they believe will benefit the parent, but for therapeutic reasons, the contents of therapy sessions will be kept confidential. Certain legal situations may also force the therapist to breach confidentiality. Finally, the therapist may talk about your care with other health care practitioners and colleagues who are or may be providing treatment for you, such as your psychiatrist, primary care physician, or the therapists on call when your therapist is out of town or when called away on an emergency. Your therapist will, within the confines of the law, maintain confidentiality in the therapist-client relationship. 12. Waiver and Release of Liability:* In seeking counseling services at extraordinarylife, you must acknowledge your understanding of the following conditions and further release extraordinarylife, its agents, affiliates, counselors, employees, and Board of Directors, from any legal liability, claim or litigation arising from your participation in their programs. 1.) All counseling will be provided by ordained ministers, certified and trained biblical counselors, certified sexual addiction therapists, or certified life coaches. The counseling staff is not licensed under the Texas Department of Professional Regulations; 2.) All counseling is provided in accordance with the Biblical principles adhered to by extraordinarylife and are not necessarily provided in adherence to local, state, or national psychiatric associations; 3.) No representation has been made, either expressly or implied, that the biblical counseling, as conducted by the above mentioned counselors, is accepted as customary psychological/psychiatric therapy within the definitional terms by those professions; 4.) It is understood that extraordinarylife will not represent a client(s) in a court of law, take sides in a custody case, represent an individual, couple, or family in a legal dispute where one, both, or all have sought counseling services at extraordinarylife; 5.) Will not release records merely upon the receipt of a subpoena alone; 6.) Recordings, i.e., audio, visual, digital, written, etc., are forbidden before during or after any session or conversation in our office, during skype sessions, phone calls, session notes, etc., to be used in a court dispute against a spouse, family member, and/or against extraordinarylife s therapists; 7.) It is understood by the counselee(s) that any grievances should be made to their counselor first, the director, and when necessary, to our Board of Directors. 13. Therapist Emergencies:* Your healing process is a priority to your therapist/coach and extraordinarylife. To better accommodate your needs and to prevent any unnecessary cancellation or rescheduling of your treatment plan, whenever possible the therapist on call will step in for your scheduled session in the event of an emergency whereby your regularly scheduled therapist may need to be absent. Page 5 of 7
Consumer Rights and Responsibilities 1. Consumer Rights Be informed of the qualifications of your counselor: education, experience, and professional counseling certifications. Receive an explanation of services offered, your time commitments, fees, and billing policies prior to receipt of services. Be informed of limitations of the counselor s practice to special areas of expertise (e.g., career development, ethnic groups, etc.) or age group (e.g. adolescents, older adults, etc.). Have all that you say treated confidentially and be informed of any state laws placing limitations on confidentiality in the counseling relationship. Ask questions about the counseling techniques and strategies and be informed of your progress. Participate in setting goals and evaluating progress toward meeting them. Be informed of how to contact the counselor in an emergency situation Contact the appropriate professional organization if you have doubts or complaints relative to the counselor s conduct. Terminate the counseling relationship at any time. 2. Consumer Responsibilities Set and keep appointments with your counselor. Let him/her know at least 48 hours prior to appointment if you cannot keep an appointment. Pay your fees in accordance with the schedule you pre-established with the counselor. Help plan your goals. Follow through with agreed upon goals. Keep your counselor informed of your progress toward meeting your goals. Terminate your counseling relationship before entering into arrangements with another counselor. If you have questions about any of these consumer rights and responsibilities please discuss them with your counselor. Thank you for allowing extraordinarylife the privilege to serve you. extraordinarylife Christian Counseling & Coaching 8 N. Main St., Suite E., Kingwood, TX 77346 Office: (281)812-0783 Cell: (281)441-9703 Skype: extraordinary.life Email: Contact@eXtraordinaryLIFE.me Website: www.extraordinarylife.me * Client(s)/parent(s)/guardian(s) is(are) responsible to initial each policy item and to sign this Intake Form wherever indicated. However, regardless of doing so or not, parties are responsible for the acknowledgement and adherence of content herein. Policies, rates, counselors, location, etc. are subject to change without notice. Existing clients may be given a verbal or written notice prior to changes that may directly affect them; except when emergencies, illness, death, catastrophes or unforeseen problems may arise. Page 6 of 7
Consent to Treatment I acknowledge that I have received and read (or have had read to me) the following documents: Client Intake Information Policy and Procedures Client Rights and Responsibilities. I have had all my questions answered fully. I do hereby seek and consent to take part in the treatment by extraordinarylife. I understand that developing a treatment plan and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand my therapy will involve a combination of therapeutic approaches that may include insight oriented, cognitive-behavioral, and/or various types of brief or Biblical solution focused counseling. Interactive play therapy is often the model of choice with children. Couple therapy is based on a combination of marital therapies including communication skills training and Biblical principles therapy, etc. My therapist will discuss the specifics of my particular treatment plan with me and inform me of the cost of my treatment. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.) I know that I must call at least 48 hours prior to a scheduled appointment if I choose to cancel the appointment. I understand that if I do not give proper cancellation notice, or show up for my scheduled appointment, that extraordinarylife will charge me for the full amount of my scheduled appointment. The exceptions to this are clearly identifiable, for example; an accident, a death in the family, illness (but not to include the excuses of I didn t get my homework done so I feel sick to my stomach and don t want to go to counseling today or I don t feel like going to counseling today so call and tell them I m sick ), etc. I understand that if payment for the services I receive is not made, the therapist may discontinue my treatment. I further understand that if my third-party does not reimburse my therapist that I am responsible for the charges of my treatment(s). I further understand that changes within extraordinarylife are subject to take place without notice. Existing clients will be given a verbal or written notice prior to such changes, except when emergencies, catastrophes or unforeseen problems arise. My signature below acknowledges that I have read and understand these statements. Signature of client I, the therapist, have discussed and/or clarified any issues of concern herein with the client (and/or his or her parent or guardian). My observations of this person's behavior and responses give me reason to believe that this person is fully competent to give informed and willing consent. Signature of therapist * Client(s)/parent(s)/guardian(s) is(are) responsible to initial each policy item and to sign this Intake Form wherever indicated. However, regardless of doing so or not, parties are responsible for the acknowledgement and adherence of content herein. Policies, rates, counselors, location, etc. are subject to change without notice. Existing clients may be given a verbal or written notice prior to changes that may directly affect them; except when emergencies, illness, death, catastrophes or unforeseen problems may arise. Page 7 of 7