"It is our goal to treat everyone with dignity, honor and respect. If at anytime you feel that you have not been treated accordingly, please discuss this with us."

Treatment Philosophy - Explanation of Brief Therapy N/A

Our approach is goal-directed, solution-focused treatment. This means that a treatment goal or several goals are established after a thorough assessment. A treatment is then planned with the goal(s) in mind and progress is made toward accomplishment of that goal in a time efficient manner. You will take an active role in setting and achieving your treatment goals. Your commitment to a treatment plan is necessary for you to experience the most successful outcome. If you ever have any questions about the nature of the treatment or your care, please do not hesitate to ask. Initial here: _______

All information between practitioner and client is held strictly confidential. There are legal exceptions to this:

1. The client authorizes a release of information with a signature.
2. The client's mental condition becomes an issue in a lawsuit.
3. The client presents as a physical danger to self. (Johnson v. County of LA, 1983)
4. The client presents as a danger to others. (Tarasoff Regents of Univ. of Calif 1967)
5. Child or Elder abuse and/or neglect is suspected. (Welfare & Institution and/or Penal Codes)

In the latter two cases, the practitioner is required by law to inform potential victims and legal authorities so that protective measures can be taken.

All written and spoken material from any and all sessions is confidential unless written permission is given to release all or part of the information to a specified person, persons or agency. If group therapy is utilized as part of the treatment, details of the group discussion are not to be discussed outside of the counseling sessions. Initial here: _______

Only after a subpoena waiver, will records be released to the attorney or court. We are not certified expert witnesses. Court appearances are provided at a fee of $100/hr, with a three hour minimum. This minimum payment (by money order, cash, or credit/debit card) is due the day before the scheduled appearance.

I authorize release of information to my Primary Care Physician, other health care providers, institutions, and referral sources for the purpose of diagnosis, treatment, consultation, and professional communication. If I am an insured client, I further authorize the release of information for claims, certification, case management, quality improvement, benefit administration and other purposes related to my health plan. Signature: ____________________________________ Date __________________________

Private Pay clients will be expected to make payments at time of service.

A $30.00 returned check fee will be applied for non-sufficient funds.

You are responsible for obtaining prior authorization for treatment from your insurance carrier. We may bill your insurance, however, you are responsible for co-payment amounts and deductibles as set by your benefit plan. Missed appointments are not covered by your insurance and the charges associated with them are your responsibility.

At any time during treatment should I become ineligible for insurance coverage or there is a change in my coverage, I will notify the practitioner and understand that I will become responsible for 100% of the bill.

Initial here: _______

Scheduled appointment times are reserved especially for you. Our answering service is provided 24 hours a day. If an appointment is missed or cancelled with less than 24 hours of notice, you may be billed according to the scheduled fee and instructions of your benefit plan, this includes EAP (Employee Assistance Program) clients who normally have no co-pay or deductible. Repeat "NO-SHOW" appointments could result in referring you back to the insurance company for reassignment to another practitioner or no further appointments being scheduled until missed appointment fees have been paid. Your insurance company cannot be billed for fees associated with missed or cancelled appointments.

If you are a private pay client, your missed appointment fee is $30 for the first session and the full appointment fee for each missed appointment thereafter.

Appeals and Grievances - For Insured Clients N/A

I acknowledge my right to request reconsideration (an Appeal) in the case that outpatient care is not certified. I understand that I can request an Appeal directly through my Health Plan and that I risk nothing in exercising this right.

I also understand that I may submit a Grievance to my Practitioner at any time to register a complaint about my care or I may send the complaint directly to my Health Plan. My practitioner has access to information and forms to facilitate this.

I authorize and request my practitioner to carry out education or counseling evaluations/diagnostic assessments, treatment, and/or diagnostic procedures which now, or during the course of my treatment become advisable. I understand the purpose of these procedures will be explained to me upon my request and that they are subject to my agreement. I also understand that while the course of my treatment is designed to be helpful, my practitioner can make no guarantees about the outcome of my treatment. Further, the therapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness, and anger. I understand that this is a normal response to working through unresolved life experiences and that these reactions will be worked on between my practitioner and me. Initial here: _______

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Client/Parent/Guardian Signature Date

__________________________________ ________________

Spouse if Present Date

__________________________________ ________________

Practitioner/Witness Signature as needed Date

General Consent for Child or Dependent Treatment N/A o I am the legal guardian or legal representative of the client and on the patient's behalf legally authorize the practitioner/group to deliver mental health care or educational services to the patient. Stepparents can only give consent for services if they have legally adopted the client/child. I also understand that all policies described in this statement apply to the patient I represent.

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Patient Name Patient Social Security #

___________________________________ ______________________

Signature of Legal Guardian/Representative Date

___________________________________ ______________________

Relationship to Patient Benefit Plan Subscriber #

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Mental Health Benefit Plan

Date: ________________________ Referred by: ____________________________

Name: __________________________________________ Sex: ___ Male ___ Female

Address: __________________________ City: ___________________ State: ______ Zip: _________

Home Phone: __________________________ May we call you at home? ____ Yes ____ No

Work Phone: __________________________ May we call you at work? ____ Yes ____ No

Age: _____ Birth date: ____/____/____ Social Security Number: _____-_____-______

Employer: ___________________________ Occupation: __________________________________

Address: ___________________________ City: ____________________ State: ______ Zip: _________

Married: ____ Yes ____ No Name of Spouse: ___________________________________________

Spouse Employed by: __________________________________________________________________

Address: __________________________ City: __________________ State: _________ Zip:________

Work Phone: ______________________ Social Security Number: ____/____/_____

Emergency Contact: ___________________________________ Phone: ________________________

Person Responsible for Payment: __________________________________________________________

Address: __________________________ City: __________________ State: ________ Zip: ________

Insurance Company: ____________________________________________________________________

Address: _____________________________ City: _________________ State: ________ Zip:________

Phone Number: _____________________________ Contact: ________________________________

Group #: ________________________ Policy #: _____________________ ID #:__________________

What concern(s) bring(s) you to counseling at this time? _______________________________________

_____________________________________________________________________________________

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What changes would you like to see as the result of counseling? _________________________________

_____________________________________________________________________________________

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Please list any previous counseling experiences:

1. __________________________________________________ Helpful? ____ Yes ____ No

2. __________________________________________________ Helpful? ____ Yes ____ No

3. __________________________________________________ Helpful? ____ Yes ____ No

4. __________________________________________________ Helpful? ____ Yes ____ No

Past Hospitalizations - Medical, Psychiatric, Chemical Dependency:

Dates: ________________ Hospital: ____________________________ Reason: ___________________

Dates: ________________ Hospital: ____________________________ Reason: ___________________

Dates: ________________ Hospital: ____________________________ Reason: ___________________

Are you under a doctor's care? ____ Yes ____ No Physician ______________________________

List any medical conditions: _____________________________________________________________

List all current medications: ______________________________________________________________

Please list any other information you feel is important for us to know at this time:

_____________________________________________________________________________________

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