Adult Individual Documents - Journey to Hope Counseling, LLC

First Name *

Last Name *

Address *

City *

Zip *

Date of Appointment *

Phone *

Email *

Birth Date

Age *

Have you been in counseling before? Was it helpful? *

What made you decide to seek services? *

How often do you exercise?

How often do you drink alcohol? *

Has anyone ever expressed concern over your alcohol/drug use? *

Do you smoke marijuana? *

Do you currently take any non-prescribed medications?

Family History

Place of Employment and Title *

How long have you been at this job?

Degree and Field of Study

I have read the Notice of Privacy Practice - Client Initials

NOTICE OF PRIVACY PRACTICES

This notice describes how medical and mental health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I am required by law to maintain the privacy of your health information and to provide you with Notice about my privacy practices, legal duties and your rights concerning your health information. I am required to abide by the terms of this notice while it is in effect. I have the right at any time to change the terms of this notice. The new notice may apply to all health information I have no matter when I received it. In the event that this notice changes, I will mail you a copy of the revised notice to the address you have provided. The new Notice will also be made available upon request.

“Protected health information (PHI)” is information about you including demographic information and information related to your past and current physical or mental health condition and related health care services. When I collect this information from you, it is stored in a chart and on a computer. I may not use or disclose any information from your record unless you provide written authorization, except as described in this Notice.

How I may Use or Disclose Your Health Information
Providing treatment services, collecting payment and conducting health care operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes.

USES AND DISCLOSURES OF HEALTH INFORMATION THAT REQUIRE WRITTEN AUTHORIZATION
Other uses and disclosures not described in this Notice require your signed authorization. For example, I must have your written authorization in order to share your PHI with your primary care physician or other mental health provider. You may revoke your authorization at any time with a written statement submitted to me. The revocation of your authorization will be effective immediately, except to the extent that: I have relied on it previously for the use and disclosure of your PHI; if the authorization was obtained as a condition of obtaining insurance coverage where other laws provide the insurer with the rights to contest a claim under the policy or the policy itself.

THERE ARE LIMITED SITUATIONS WHEN I AM PERMITTED OR REQUIRED BY LAW TO DISCLOSE HEALTH INFORMATION WITHOUT YOUR SIGNED AUTHORIZATION. THESE INCLUDE:

Child, Elderly or Disabled Adult Abuse- If I know or suspect that a child under the age of 18, an elderly person or disabled person has been abused or neglected, I am required by law to release PHI and make a report to the appropriate authorities and may be required to provide additional information.

Safety- I may disclose your PHI in order to reduce or prevent an imminent or serious threat to the health and safety of you or others. If a client threatens to harm himself/herself or others, I may be obligated to seek hospitalization for him/her, to contact family members or others who are reasonably able to prevent or lessen the threat and to contact the person whose safety has been threatened. If you report you have been sexually exploited by a mental health professional, I must report this.

Legal- I am required to release your PHI in compliance with a court order or subpoena. If a client files a complaint or lawsuit against me, I may disclose relevant PHI in order to defend myself. I may disclose your PHI to a law enforcement official for law enforcement purposes.

Worker's Compensation- I may disclose your PHI as necessary to comply with worker’s compensation laws.

Specialized government functions- If you are a member of the U.S. Armed Forces, I may disclose your PHI as required by military command authorities. I may also disclose PHI to authorized federal officials for national security reasons.

Vocational Rehabilitation Services and Similar Agencies- I may disclose PHI to agencies from which you are requesting assistance.

Health Oversight Activities- I may disclose PHI if requested by a government agency for health oversight activities.

Disaster Relief- I am permitted under the Privacy Rules to provide your PHI to disaster relief agencies.Marketing. I may contact you to provide appointment reminders (such as voice mail messages, postcards, or letters) or to give you information about other treatments or related services that may be of interest to you.

CLIENT'S RIGHTS

You have the right to:

Access- You have the right to request and inspect a copy of your health information in my records, with limited exceptions. Requests must be made to me in writing. I may deny your access to a portion of your health information. Access or denial will be provided within 30 days. If denied, you may request a review of the denial. Examples of reasons why I might deny the request include, but are not limited to the following: a determination that doing so might be harmful to you or another person. Because these are professional records, the contents can be misinterpreted and/or upsetting to an untrained reader. For this reason, if I decide to release your PHI for your review, I will make an appointment for your review the information in my presence so that you are provided with an opportunity to discuss the contents. Fees apply for this service. If you wish not to review the information with me, I recommend that you review the contents with another mental health professional. If you prefer, I will prepare a summary of your health information. You will have the right to a copy of parts or all of your health care information. Fees apply for this service. Current fees include $0.25 for each page copied, $15.00 per hour for staff time to locate and copy your PHI and postage, if you want the copies mailed to you. If you request an alternative format, I will charge a cost-based fee f or providing your health information in that format.

Amendment- You have the right to request that I amend your health information. This request must be made in writing and include the reasons for the request. I will consider the request, but I do not have to agree to the request. I may deny the request if the information was not created by me (unless you prove that the creator of the information is no longer available to amend the information), the information is not part of the records used to make decisions about you, if I believe the information is correct and complete, if I feel the information could be harmful to you to another person or if you would not have the right to see and copy the information as described above. If I accept your amendment, I will attach it as a permanent document in your health care record. If you make reference to specific documents in your health care record, I will append a note to each such document referring a future reader to your amendment. If you do not identify any specific documents or simply state “all” (or some similar language), then I will add your amendment as a separate document into the chart, but not append notes to any other documents.

Restrictions- You have the right to request restrictions on certain uses and disclosures of your PHI for treatment, payment and health care operations. I am not required to agree. If I do agree, I will abide by our agreement (except i n an emergency). Alternative communications- You have the right to request and receive confidential communications of your PHI by me. You may request to receive communication by alternative means or at alternative locations. For example, you may request that I use a specific telephone number or address to communicate with you. Requests must be made to me in writing and must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location.

Disclosure accounting- You have the right to receive an accounting of certain disclosures of your PHI made by me. Requests must be made in writing. You may ask for disclosures made up to 6 years before the time of your request. If you request this accounting more than once in a 12-month period, I may charge you a reasonable, cost based fee for responding to the additional requests.You also have the right to receive changes in these above stated policies. You have a right to receive a copy of this Notice.

QUESTIONS AND COMPLAINTS

If you have questions about this Notice, concerns about the privacy rights or disagree with a decision I make regarding privacy, you may discuss this with me. You may also send a written complaint to U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington, D.C. 20201. Complaints must be filed within 180 days of the time you knew or should have known of the violation. I support your right to the privacy of your PHI and will not retaliate against you for exercising your right to file a complaint.

Welcome! It is my desire to assist you in making informed decisions about your treatment. As a client of psychotherapy and as a consumer, you have certain rights. Therefore, I will explain the information you are entitled to know, such as my view of the therapeutic process, and my expectations for the cooperative working agreement. Please feel free to ask questions about any of the following information.

1. Education and Training:
Master of Arts degree in Counseling from Liberty University, April 2015
Master of Science degree in Management Information Systems from Florida Institution of Technology in May 2006
Bachelor of Science degree in Management Information Systems from the University of Alabama in Huntsville, May 2003

2. Credentials, certifications, and Licenses:
Professional Licensed Counselor 3767

3. The Therapeutic Process:
Counseling has both benefits and risks. Benefits for people who undertake counseling often include a reduction in feelings of distress, more satisfying relationships, increased clarity and resolution of specific problems. Growth nearly always brings change, and sometimes change (even positive change) causes stress. Potential risks of counseling involve recalling unpleasant aspects of your personal history that may bring up distressing thoughts and feelings. Every effort will be made to assist you to reach your therapeutic goals. If you have any concerns about your progress or the results of your counseling experience, please talk with me at any time during our work together.

4. General Structure of Therapy Sessions:
I do psychotherapy in weekly or biweekly sessions of 50 to 90-minute periods. Length or frequency of sessions can be increased or decreased to reflect your therapy needs. It should be noted that if you arrive late for a session, you are still responsible for the total fee of the session and time will still end as usual.

5. Canceling Information and Scheduling:
You must call to cancel a session equal to and/or no less than 24 hours in advance or you will be charged $75. Certain circumstances may be taken under consideration if this should happen. Appointments can be made either by phone, face to face or by email.

6. Payment:
My fee is $110 for a 53-minute session and $175 for a 90-minute session. Sessions can be increased or decreased as needed, wherein the cost would appropriately reflect this change. Payment is expected upon receipt of services. There is a $10 late fee for past due payments and if I receive a returned check, a $35 fee will apply to the total amount. Phone consultations of 15 minutes or more will be charged my office visit rates.

The standard fee for all court-related work is $325 per hour. The standard fee for all other services rendered including but not limited to phone calls and email time (non-administrative in nature), report writing, consultations and authorized release of information requests will be billed at a rate of $110 per hour. Fees for these services are not covered by insurance and will be your responsibility. All requested letters and paperwork start at a fee of $25.

7. Messages:
Every effort will be made to return calls and/or emails within a 24-hour period, unless otherwise stated. I will attempt to check my messages during my days off but no guarantee will be made to call you within the 24 hours. I will however contact you on my next business day.

Email communication outside of counseling sessions are limited. Please email to change an appointment or communicate a special request. Excessive emails, phone calls or harassment will result in discontinuation of the patient/client relationship.

8. Emergencies:
While my practice is not prepared to handle emergencies, please either dial 911 or head to your nearest Emergency room. I have also given you an emergency phone list which you should utilize. Once you have either called 911 or gone to the emergency room, please leave me a voice mail indicating you have done so.

9. Confidentiality:
The information provided by and to a client during therapy sessions is legally confidential and will not be released without the client’s signed consent. Exceptions to the rule of confidentiality:

If I feel there is a threat of you harming yourself and/or other(s).
If I suspect child or dependent adult abuse/neglect either past or present.
If there are collection proceedings.
If a client files a grievance against a therapist.
If there is a court order for counseling.

You should be aware that confidentiality cannot be assured for electric communications like cell phones, emails, and fax. You cannot hold your counselor responsible or liable for breach of confidentiality if you choose to communicate with your psychotherapist by these electric means. You also give permission for such electric communications to take place in consultation with your counselor.

10. Feedback
Please let me know if you ever feel your needs are not being met in counseling. It is important that we can openly discuss your treatment plan and make appropriate adjustments. Premature counseling termination include; conflict phobia, shame, and feelings of hopelessness. I will request for feedback at every counseling session. Your honesty will increase counseling efficiency and treatment success.

11. Client Rights:
You are entitled to information about my methods of therapy, techniques used, duration of counseling (if we are able to determine it), and the fee structure.
You can seek a second opinion from another therapist or terminate therapy at any time.

In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers or certifies the licensee, registrant, or certificate holder.

12. Records:
Records include identifying information, dates of sessions, an initial assessment, treatment plan, and any consultations or collateral contacts made. Your records will be stored safely with attention to your privacy. They can only be released with your written permission and direction. I may sometimes summarize the content related to the request rather than release the entire record.
You will not be given a photocopy of your record, but you will be granted reasonable access. If you choose to read your record, it is my policy to be present in order to respond to any questions or confusion you may have about the recordings.

13. Termination:
Termination will usually be agreed upon mutually, however, you are free to terminate at any time. In rare instances, it may be in my best clinical judgment to terminate services despite your wish to continue. These instances can include: treatment goals have been met, overt aggression, a need for special services outside the area of my competency, and/or a failure to meet the terms of our fee agreement.
Should this occur, the reason for termination will be discussed with you, and you will be helped to make different plans for yourself, including a referral to more appropriate resources. If you have any questions and/or concerns, please feel free to ask.

14. Policies:
Upon entering the therapy room, I ask that you turn off anything that rings, beeps, buzzes, etc. You are expected to turn off all your gadgets and make necessary arrangements, so you will not need to be disturbed during your appointment. It is recommended that you leave electronic equipment in your car. This will save you time and expense.

Payment is required at each appointment. Cash, Check, and Credit Cards are accepted and as stated earlier, a $35.00 fee will apply for returned checks.

Digital Signature

My digital signature below indicates that I have read the preceding information and understand my rights as a client and agree to abide by the terms specified in the Consent to Treatment document.

Family History

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