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Counseling Services Application How did you hear about us?___________________________ Personal Information Assigned Counselor: First name Middle initial Last name Today's date Mailing/Street address City
  Counseling Services Application How did you hear about us?___________________________  Personal InformationAssigned Counselor: First name Middle initial Last nameToday's dateMailing/ Street  addressCityStateZipHome phoneBusiness phoneCell phoneBirth dateSex:   Male   FemaleSocial security numer List present or pre!ious health prolemsList any medications you are currently ta ing  Spouse Parent Information if under ! First name Middle initial Last nameMarriage dateStreet addressCityState ZipHome phoneBusiness phoneBirth dateSex   Male   FemaleSocial Security #umer List present or pre!ious health prolemsList any medications you are currently ta ing Insurance Information Payment Arrangements:   Client    ard   Insurance  $nsurance company name%olicyholder%olicyholder&s date o irth(pplicant&s relationship to policyholder      Sel   Spouse   Child   )ther $nsurance company addressCity State Zip%hone %olicy numerCo*payment amount+roup numer Secondary $nsurance company name%olicyholder%olicyholder&s date o irth(pplicants relationship to policyholder      Sel   Spouse   Child   )ther Street addressCit State Zi%hone%olicy numer Co*payment amount+roup numer  #ther Information $P%&AS& C#'P%&(& (HIS S&C(I#)* ,hat do you hope to change or accomplish y see ing help at this time- .se the ac o the orm i more room is needed01List any agencies or other proessionals 2ho ha!e pro!ided you counseling ser!ices in the past0 .se the ac o the orm i more room is needed01SignatureSignature  Counseling Services Authorization for Release of Confidential Information The Counseling Center I authorize The Counseling Center and the persons or entities listed below, or their representatives, to mutually release and disclose my health information.I have received and reviewed The Counseling Center’s   Notice of Privacy Practices . I understand that only employees of The Counseling Center may ask me to sign this authorization.I understand that by signing this General Authorization  I am authorizing The Counseling Center to disclose my health information to the persons and entities listed below and that any health information or other confidential information in the  possession of the persons and entities listed below may be disclosed to The Counseling Center. My health information includes, without limitation, any records, reports, test results, opinions, assessments and any other information relating to medical, emotional, educational or psychological condition. isclosure may also be made to describe my condition and progress and to discuss treatment. I understand that I may revoke this authorization at any time by sending a written notice of revocation to the counseling supervisor at The Counseling Center office where I am receiving counseling. I understand that my revocation of this General  Authorization  will not affect a disclosure that The Counseling Center has already made under this authorization.I understand that information used or disclosed under this authorization may be sub!ect to re disclosure by the recipient, and mayno longer be protected by The Counseling Center’s confidentiality rules.I waive any right of privacy that I may have in connection with the disclosures hereby authorized.This authorization is only valid until ################################ $fill in date%, or until three months after my file is closed at The Counseling Center. &rimary Insurance Company 'ddressClient’s Initials(econdary Insurance Company'ddressClient’s Initials)ishop*&astor*+cclesiastical eader'ddressClient’s Initials -ame 'ddress Client’s Initials -ame'ddressClient’s Initials -ame 'ddressClient’s Initials -ame'ddressClient’s InitialsClient’s signatureateClient’s signatureate -ame of parent or guardian  if client is under 18 /-ame of parent or guardian  if client is under 18 /(ignature of parent or guardian  if client is under 18 /ate(ignature of parent or guardian  if client is under 18 /ate0itnessate0itnessateClient -ameClient -ame  C OUNSELING  - D ESCRIPTION   O  S ER!ICES   T #E  C OUNSELING  C ENTER  0e welcome you to The Counseling Center, and hope that your visit will be worthwhile. The following information is important for your consideration. 1our goals are more likely to be met when you understand the nature and limitations of counseling. Go$ls $nd Outco%es 2enerally, counseling is most useful in helping individuals help themselves or improve their relationships by changing feelings, thoughts, and*or behaviors. 1ou determine the nature and amount of change you wish to make. &enefits $nd Ris's Most people e3perience improvement or resolution to the concerns that brought them to counseling, but of course, there are no guarantees4 and there are some risks. 5or e3ample, counseling could open up new levels of awareness that may cause discomfort. Length of Ther$() The Counseling Center offers a short term counseling focus. This usually means fewer than twelve sessions. If it appears your situation re6uires more than twelve sessions, your counselor may discuss a referral to a program that can accommodate that need. Confidenti$lit) 0e understand that the information you share in counseling can be very personal and that you may not want us to disclose this information to others without your authorization. )y signing this  Description of Services, you acknowledge receipt of The Counseling Center     Notice of Privacy Practices. This document describes your rights andour obligations regarding the use and disclosure of that information. 'll clients will be asked to sign an 'uthorization for 7elease of Confidential Information. 8ffice personnel will not release confidential information without this written authorization, unless such release is otherwise authorized or re6uired by law. 5or e3ample, the law may re6uire us to disclose confidential information if there is reason to believe that a child has been abused or neglected, or that you may be in danger of harming yourself or others. P$)%ent for Ser*ices The fee for services is 9:; per ;< minute session. 'dditional time will be charged in one half hour increments. Clients are responsible for payment of services. &ayments are made to the office at the conclusion of each visit. 5or your convenience, we accept =isa and MasterCard debit or credit/ in addition to cash and checks. 5or your  protection, we will accept credit and debit cards only when card information is provided to the office in person or by  phone.   )e aware that insurance companies may re6uire a mental health diagnosis and additional information. If you are using insurance and have concerns, please discuss them with your counselor.'s a courtesy to our clients who have insurance, we will submit services to your insurance company. Client is ultimately responsible for payment if insurance does not make payment and co payment is due at time of service.'ny returned checks will be charged a fee of 9>; for each occurrence to your account. The initial interview, in home therapy and play therapy may be a slightly different charge and are covered differently  by insurance companies. 7eduction in fees needs to be negotiated with your Counselor during the first session. C$ncell$tion of +((oint%ent 8n occasion, a situation may arise which prevents you from keeping a scheduled appointment with your counselor. 's a courtesy to your counselor and the office, please notify us at least 24 hours  in advance of your appointment if you cannot keep it. +3cept in emergency situations, you will be personally charged the current hourly fee for late cancellations or not showing for an appointment.  (hould collection become necessary, I*0e agree to pay all attorney?s fees, court costs, filing fees, and all collection costs up to @@.@A of the amount owing which may be assessed by any collection agency retained to pursue the matter. I*0e further agree to pay a finance charge of B B*>A per month annual percentage rate of B:A per year/ of the unpaid balance. +ssign%ent of Counselor 1ou may be seen by a licensed counselor or a supervised intern. ollo,-U( 8ccasionally, we follow up with clients to determine if treatment was successful and results were lasting over time. May we contact you in the future Circle one/ 1+(-8If you change your mind about allowing us to contact you in the future, you must send a letter to us to advise us of your decision. Grie*$nce If you have concerns about any aspect of the services you are receiving, you should address the matter with your counselor. If you are unable to find a resolution to your concerns, you may talk with the counseling supervisor. If a resolution is still not reached, you may contact the counseling group manager. Other +re$s of Discussion 0e encourage you to ask your counselor about areas of concern. 5ollowing are 6uestions that you may want to consider askingDB.0hat is the background of your counselor>.0hat does your counselor feel most 6ualified to treat@.5ollowing the assessment interview, you may ask how your counselor intends to help you, or what methods will be used, and how long that may take.E.1ou may ask about other interventions such as support groups, marriage counseling, family therapy, etc.;.If a referral is recommended, how will that be handled Ple$se $rr$nge for s%$ll children to re%$in $t ho%e unless s(ecific$ll) $s'ed to ring the% $s ($rt of f$%il) ther$(). Children %$) not e left un$ttended in the ,$iting $re$. I have read the above information, and understand that I am encouraged to ask 6uestions, and give input regarding the counseling process at anytime. If there is anything in this form that I do not understand, it is my responsibility to seek clarification. CLINT! INS#$ANC! %ishop&Pastor&cclesiastical! (ignature ate ################################################## &rint name   (ignature ate  ################################################## &rint name The Counseling Center 345 #orth Main Street
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