The following information is designed to assist me in becoming better acquainted with you and in providing you with the help you need. All information is confidential and will remain in your files.
* Please print and fill out all forms to bring with you to the first session.
Date of Birth_________________Age______
Home Phone___________________Work Phone____________________
Is it acceptable to contact you at home? (circle) Y N
If “no,” then how may I contact you?_______________________________
Emergency Phone (see Disclosure Form concerning confidentiality)
Is it acceptable to contact you by e-mail? (circle) Y N
How often do you check your e-mail?______________________________
Martial Status (circle) Single Married Divorced
Separated Partnered Widow/Widower
Names of Children, Ages________________________________________
Family history of (circle all that apply)
Depression Suicide Attempts Anxiety
Eating Disorders Mental Illness Violence
Sexual Abuse Emotional Abuse Divorce
Alcoholism/Drug Addiction Chronic Illness (please explain)____________
Insured’s Name____________________________Birth Date___________
Your relationship to the insured: (circle)
Self Spouse Child Other
Insurance ID#___________________Policy Group#__________________
Insurance Plan Name__________________________________________
Personal Physician (see Disclosure Form concerning confidentiality)
Have you experienced any recent changes in any of the following? (circle all that apply)
Sleep Nightmares Amount of Exercise
Sexual Desire Eating/Appetite Weight
Do you consume any alcohol? (circle) Y N
Circle frequency: Less than 1x/mo 1-3x/mo
1x/week Several x/week Every day
How would you characterize your overall health? (circle)
Poor Fair Good Excellent
Have you been under the care of a psychiatrist, psychologist or counselor?
(circle) Y N
If yes, please give the name, date and location of therapy and briefly explain the nature of the issue(s) which required attention.
When was your last appointment with any of the above?
Please state the reason for which you are seeking counseling and what you would like to be different in your life when you are done with therapy:
Please indicate your major life stressors of the past 12 months
(circle all that apply)
Serious Illness or Injury Death of a Close Friend or Family Member
Major Illness in Family Gain of New Family Member
Divorce/Separation Job Change Other___________________
Have you ever been hospitalized for a psychiatric or emotional health reason? (circle) Y N
When Where Reason Outcome
Have you ever been in an alcohol or drug treatment program?
(circle) Y N (If yes, circle) Inpatient Outpatient
When Where Outcome
Please indicate any of the following that you have experienced (circle)
Death of mother Your age at occurrence_______
Death of father Your age at occurrence_______
Death of child Your age at occurrence_______ Child’s age_______
Death of sibling Your age at occurrence_______ Sibling’s age______
Desertion by mother as a child Your age at occurrence_______
Desertion by father as a child Your age at occurrence_______
Divorce of parents Your age at occurrence_______
Sexual abuse Emotional abuse Physical abuse
Violence in the family Mental illness of a family member
How do you get along with your present spouse or partner?
How do you get along with your children?
How do/did you get along with the members of your family of origin?
What is the nature of your employment?
How long have you been employed in your current job?
How satisfied are you in this job? (circle)
Not very satisfied Somewhat satisfied Comfortable Very satisfied
Are you satisfied that the income from your job adequately covers your living expenses? (circle)
Not very satisfied Somewhat satisfied Comfortable Very satisfied
Do you have any other sources of income? (circle) Y N
How significant a role does spirituality play in your life? (circle)
None Somewhat important Significant Very significant
Name of person who referred you to me:___________________________
May I have your permission to thank this person for the referral? (circle)
Disclosure and Information Client Form
Counseling Orientation: As a counselor working in a relational, conversational manner, I will explore with you the problem, or problems you bring with the goals of exploring your life story and learning to love others well. I believe that seeking truth and love are of the utmost importance, and many of the results of your counseling experience will depend upon your willingness to identify and face what is true in your life. My approach is psychodynamic and I utilize elements of several different treatment modalities, including Object Relations Theory, Existential Therapy, Attachment Theory, and Cognitive Therapy.
Billing and Insurance Information: The fee for counseling is $90.00 for a 50 minute session. I do offer a sliding scale pending on each client’s unique financial needs. Payments are to be made at the beginning of each session unless an alternate payment plan is previously agreed upon. I accept checks or cash. Appointment cancellations need to be made at least 24 hours in advance or you will be charged for the missed appointment (illness and emergencies are exceptions). Fees are subject to change with prior notification.
Scheduling Appointments: Appointments will be scheduled after each session. Do not assume that a particular appointment time will be held for you each week, unless it is agreed upon.
Your Rights As A Client
Choosing a Counselor: It is your right to choose a counselor who will best suit your needs. You may seek a second opinion or terminate therapy at any time.
Confidentiality: As a professional counselor in the state of Washington, I am bound by law and ethical standards to keep any information you share with me in the strictest confidence. Confidentiality is your legal privilege.
5 Legal Exceptions to Confidentiality: I may legally and ethically share information with others if: 1) the client gives written permission, 2) the client suggests a crime or harmful act against self or others, 3) the client is a minor and there is reason to believe that the minor is the victim or subject of a crime, 4) the client brings legal charges against the counselor, and 5) if the counselor is required to testify in court under a subpoena. Please read the attached brochure entitled “Client and Counselor Responsibilities and Rights” as defined by the state of Washington.
Whenever possible, exceptions to confidentiality will be discussed before any action is taken.
Consultations: It is a regular part of my practice to consult with other mental health professionals regarding my clients. Client confidentiality is strictly maintained throughout these consultations. My purpose is to serve you best, which may include gaining other perspectives from trusted colleagues.
State Information: I am a Licensed Mental Health Counselor in the state of Washington.
Unprofessional Conduct: If my behavior has been unprofessional in any way, please contact the Department of Health.
State Contact Information: Department of Health
P.O. Box 47869
Olympia, WA 98504-7869
Contacting Me: You may call and leave a message with my voice mail, which I check often. Phone calls should be limited to appointment scheduling and emergencies.
Emergencies: In case of emergency and I am unreachable, please use one of the following numbers for help:
General Emergencies: 911
Care Crisis Response Service: (800) 584-3578 (425) 258-4357
Crisis Clinic: (800) 244-5767 (206) 461-3222
I have read the information on Collective Hope Counseling. I have had the opportunity to ask any questions about her and/or my counseling program. I agree to the conditions in Collective Hope Counselings disclosure and information statement.
Collective Hope Counseling
TREATMENT PROGRAM AND COUNSELING AGREEMENT FORM
THE PROVISION OF THE FOLLOWING INFORMATION AND WRITTEN ACKNOWLEDGEMENT OF ITS RECEIPT ARE REQUIRED BY WASHINGTON STATE LAW. PLEASE READ IT CAREFULLY. WE WELCOME THE OPPORTUNITY TO DISCUSS ANY QUESTIONS OR CONCERNS YOU MAY HAVE REGARDING THIS AGREEMENT OR OUR TREATMENT AND EDUCATIONAL PROGRAMS.
YOUR RIGHTS AS A CLIENT:
As a client of a registered and/or licensed counselor, you have privileged communication under the laws of the State of Washington. You may give written permission for your counselor to disclose that information. If you are being seen in family or couples treatment; information shared in any individual meeting may be shared by your counselor. The informational brochure from the State of Washington lists additional exceptions to your right to confidentiality.
You always have the right to request a change in treatment or to refuse treatment. You also have the right to view, copy, or request a change in your records. The Counselor Credentialing Act provides protection for public health and safety and empowers Washington State citizens by providing a complaint process against those counselors who would commit acts of unprofessional conduct. The informational brochure printed by the State of Washington Department of Health lists conduct, acts, or conditions that constitute unprofessional conduct.
It is very important that your work here meets your needs. If you believe you are not being helped, it is important that you discuss it with your counselor so that the difficulty can be resolved. If the situation cannot be resolved, your counselor will assist you in finding appropriate, alternative treatment.
APPOINTMENTS AND FEES:
Appointments are scheduled with a frequency believed to be most beneficial. The time scheduled for your session is set-aside specifically for you. Please understand that payment of your bill is part of your treatment. If you miss a session without cancelling, or if you cancel with less than 24 hours notice, you will be charged in full for the missed time. If you are late for a session, you will be seen for the remainder of your scheduled time and charged the full rate. Full payment is due at the time of service and must be in the form of either cash or check. Extended payment plans are handled on an individual basis only.
Any work done related to a legal issue on your behalf will be charged on an hourly basis for the time spent on your case. This includes meeting with your attorney, writing reports, travel and preparation time.
The parent(s) or guardian(s) of a minor are responsible for full payment.
INFORMED CONSENT AND REQUEST FOR SERVICES:
It has been explained to me that counseling is not an exact science, and that I have the right to have a clear description of the nature and character of the proposed counseling. I also realize that I have treatment options outside Collective Hope Counseling including counseling at all and that no guarantee or assurance has been made to me as to the results that may be obtained from treatment at Collective Hope Counseling.
My signature below verifies that:
1. I have freely elected the counseling/treatment program Collective Hope Counseling in good faith and without duress.
2. I give permission for Collective Hope Counseling to release psychological reports to referring physician(s), mental health practitioners(s), or agencies.
3. I understand that any therapy, diagnostic work, testing, video and/or audiotaping (conducted at my consent) may be reviewed by a supervising or consulting psychologist designated by Collective Hope Counseling.
4. I am aware that treatment through Collective Hope Counseling is not an emergency service and I have been informed of phone numbers to call in the event of an emergency during evening and weekend hours.
5. I have received a copy of the Washington State Department of Health brochure on Counseling and have been informed about the purpose of the Counselor Credentialing Act.
6. I have received a copy of the published fees for services provided by Collective Hope Counseling and have made a financial agreement for services rendered to me.
7. I have received a written disclosure that includes the registration, certification, and/or license number of Collective Hope Counseling therapist. This disclosure also includes information regarding his treatment philosophy, education, and experience.
8. I agree to defend, indemnify, and hold Collective Hope Counseling, its principles, agents, and employees harmless from and against any and all liability, loss, or damage that I, as a client may suffer as a result of claims, demands, cost, or judgments arising out of, in connection with, or incident to Collective Hope Counselings performance of services.
9. I have read this Treatment Program Statement and Client Agreement and I understand it. I have asked any questions that I desired in regard to this agreement, fees, and payment policy.
Client Signature Date
Counselor Signature Date