Rebecca Jarrell, MA, LPC

Rebecca Jarrell, MA, LPC

Licensed Professional Counselor

ADULT CLIENT INFORMATION

Client Name: ______

Last First

Address: ______

City: ______Zip: ______

OK to leave message/appt. reminder

Phone: Home ______No Yes

Mobile/other: ______No Yes

Email address: ______No Yes

Sex: M F SSN: ______-______-______Date of Birth: ____/____/____

Whom may I thank for referring you? ______

Emergency contact name and number: ______

Please check one:

____I, undersigned, know that Rebecca Jarrell is an out of network provider and I agree to the fee of $120 per hour. I understand that if I choose to file with my insurance company, Rebecca Jarrell will provide the necessary documentation for me to submit to my insurance company.

____I, undersigned, certify that the above client has insurance coverage with ______

and assign directly to Rebecca Jarrell all insurance benefits. I hereby authorize Rebecca Jarrell to release all information necessary to secure the payment of benefits. I further authorize the use of this signature on all insurance submissions.

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Responsible Party Signature Relationship Date

______/_____/_____

Rebecca Jarrell, MA, LPC Date

Rebecca Jarrell, MA, LPC

Licensed Professional Counselor

Client Name: ______Date: _____/_____/_____

BASIC RIGHTS FOR ALL CLIENTS

·  The right to impartial access to treatment regardless of race, religion, gender, age, ethnicity or handicap.

·  The right to considerate and respectful treatment and recognition of your personal dignity.

·  The right to a written statement of your rights.

·  The right to be informed of your rights in a language that you understand.

·  The right to adequate and humane services regardless of financial support.

·  The right to have services provided in the least restrictive environment possible.

·  The right to participate in treatment decisions.

·  The right to obtain information about treatment recommendations and alternatives.

·  The right to obtain information about your condition and prognosis from your clinician.

·  The right to a periodic review of your treatment plan.

·  The right to be involved in planning termination of treatment.

·  The right to terminate counseling services at any time, for any reason.

·  The right to be informed of alternatives available when you leave treatment and specific follow up recommendations will be given.

·  The right to report any incidents of abuse or neglect, whether you are a victim or an observer.

·  The right to expect that all communication and records pertaining to your treatment will be treated as confidential, except as otherwise required by law.

·  The right to be told of any experimental treatment approach recommended for you and you must give your written consent prior to any such approach can be used.

·  The right to present complaints concerning the quality of care you received.

·  The right to request a review of the practices and procedures for ensuring clients rights and for addressing questions or complaints about your individual treatment plan.

·  The right to be told in advance of all estimated charges for services provided.

·  The right to withdraw your permission at any time in matters to which you have previously consented to.

·  The right to request the opinion of another clinician, at your own expense.

I certify that:

_____ I have received a copy of this document prior to treatment.

_____ This document was presented to me in a language that I understand.

Signature: ______Date: _____/_____/_____

Witness: ______Date: _____/_____/_____

Rebecca Jarrell, MA, LPC

Licensed Professional Counselor

Client Name: ______Date: _____/_____/_____

NO SHOW/CANCELLATION POLICY

I understand that I must notify Rebecca Jarrell’s office at least 24 hours prior to my appointment if I plan to cancel. I further agree that if I am more than 15 minutes late for my appointment, I will be considered a no-show. Otherwise, there will be a no-show fee of $65. I also understand that this fee must be paid prior to my next visit.

Forensic Rates

·  $250 per hour (or portion of hour) for legal testimony or deposition.

·  $150 per hour (prorated) for transportation, waiting, and preparation for legal testimony or deposition.

·  $150 per hour (prorated) for consultation with attorneys or litigants (in person or via phone), report writing, review of records, and any other service associated with a legal dispute.

·  If I am subpoenaed or otherwise committed to appear in a legal case involving you, and the appearance is cancelled with less than 48 hour’s notice, you will be billed $750 to offset the cost of a lost day of my work. These rates are enforced whether you or another litigant in a case involving you have compelled me to become involved. Failure to keep your account current may result in legal action or collection agency intervention.

Phone Consultation

There are fees associated with work provided outside of your therapy session.

Telephone consultations that exceed 10 minutes are billed at a rate of $2 per

minute. Reports and letters written at your request, and exceeding 10

minutes of work are $60 per 30 minutes.

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Signature of client or guardian Date

______

Print name of above Relationship to client

______/_____/_____

Therapist Date

Rebecca Jarrell, MA, LPC

Licensed Professional Counselor

Client Name: ______Date: _____/_____/_____

CONSENT FOR COUNSELING

I, the undersigned hereby voluntarily agree to individual and/or family counseling services provided by Rebecca Jarrell. I am aware that the practice of counseling is not an exact science. As a consequence, I acknowledge that no guarantee has been made to me concerning the result of any evaluation or treatment that may be rendered. Furthermore, I understand that evaluation and treatment may involve discussion of personal events in my own history that may be discomforting.

LIMITATIONS ON CONFIDENTIALITY

Information about the diagnosis, evaluation, or treatment of a client is usually confidential information that may only be disclosed to authorized people. Only the client may give written permission for release of any pertinent information before information can be released to another person or entity. Confidentiality will be maintained in all other respects.

The following are exceptions to confidentiality that each client needs to understand in advance:

·  If a counselor learns of child or elder abuse that is currently taking place or has the possibility of recurring, the counselor is legally required to report that abuse to the proper authorities.

·  If a counseling client discloses an intention to harm themselves or someone else, the counselor is required to report that intention to the proper authorities.

·  If a subpoena, court order, or other statute requires disclosure.

PRIVACY POLICY

This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can access your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

As my commitment to your privacy, I am required by law to maintain the confidentiality of your health information and must provide you with the following information. The following circumstances may require me to disclose your health information:

·  The public health authorities and health oversight agencies authorized by law to collect information.

·  In response to a court order in lawsuits or similar proceedings.

·  If required to do so by a law enforcement official.

·  When necessary to reduce or prevent a serious threat to your health and safety of the health and safety of another individual or public. I will disclose to a person or organization able to help prevent the threat.

·  If you are a member of the US or foreign military forces (including veterans) and if required by the appropriate authorities.

·  To federal officials for intelligence and national security authorities authorized by law.

·  To correctional institutions or law enforcement officials if you are an inmate or under custody of a law enforcement official.

·  For Workers Compensation or similar programs.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

·  You can request communication about your health and related issues in a particular manner of at a certain location. For example, you may request that I contact you at home, rather than work. I will accommodate reasonable requests.

·  You can request restriction in my disclosure of your health insurance for treatment, payment, or operation. You can request that I restrict disclosure of health information to certain individuals. I am not required to agree to your request. However, if I do agree, I am bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary for treatment.

·  You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including medical records and records, but excluding psychotherapy notes.

·  You may ask me to amend your health information if you believe it is incorrect or incomplete, as long as the information is kept by or for my practice. To request an amendment, a request must be in writing and a reason that supports your request must be provided.

·  You are entitled to receive a copy of this notice of privacy at any time.

·  If you believe your privacy rights have been violated, you may file a complaint with my practice or with the Department of Human Services.

·  All complaints must be submitted in writing. You will not be penalized for filing a complaint.

·  I will obtain your authorization for usage and disclosure of health information that are not identified in this notice or permitted by law.

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Client/Parent/Guardian Signature Date

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Therapist Signature Date

Rebecca Jarrell, MA, LPC

Licensed Professional Counselor

CREDIT CARD AUTHORIZATION FORM

Please Print

Name as it appears on card: ______

Email Address: ______

Credit Card Type: ___ Visa ___ MasterCard

___ American Express ___ Discover

Credit Card Number: ______

CVC #: Last three digits on back of card: ______

Expiration Date: ______

Billing Address: ______

City: ______State: ______Zip Code: ______

Phone Number: ______

Bill my credit card for each visit/ or copay: $______Initials

Bill my credit card for each missed appointment: $65. ______Initials

I agree that all information provided is accurate and complete. I also acknowledge that services may be immediately terminated at Rebecca Jarrell’s discretion if any charges are declined or charge backs are claimed against any outstanding amount. Disputes to amounts should immediately be reported to Rebecca Jarrell, MA, LPC.

______

Authorized Signature Date

Rebecca Jarrell, MA, LPC

Licensed Professional Counselor

ADULT ASSESSMENT FORM

Client’s name: ______Date: ______

Gender: ____ F ____ M Date of birth: _____/_____/______Age:______

PRIMARY REASON(S) FOR SEEKING SERVICES AT THIS TIME:

___ Anger management ___ Anxiety ___ Coping skills ___ Depression

___ Financial stressors ___ Fear/phobias ___ Mental confusion ___ Sexual concerns

___ Infidelity ___ Parenting issues ___ Alcohol/drugs ___ Communication issues

___ Other mental health concerns (specify): ______

______How long has this been an issue for you? ______

Counseling/Prior Treatment History

Information about past and present treatment:

Counseling/psychiatric treatment:______

______
Suicidal thoughts/Attempts: ______

______Drug/alcohol treatment: ______

______

Information about family/significant others (past and present): ______

Please check behaviors and symptoms that are problematic for you:

____ Aggression ____ Communication issues ____ Parenting issues

____ Alcohol dependence ____ Drug dependence ____ Recurring thoughts

____ Anger ____ Gambling ____ Financial stressors

____ Infidelity ____ Anxiety ____ Sleeping problems ____ Hopelessness ____ Cyber addiction ____ Impulsivity

____ Suicidal thoughts ____ Depression ____ Irritability

____ Lack of communication ____ Withdrawing ____ Judgment errors

Briefly discuss how the above symptoms impair your ability to function effectively: ______

What are your reasons for seeking therapy at this time? ______

Family Information

Those currently living in your home (name and age):

Children: ______

______

Others: ______

Marital Status (more than one answer may apply)

____ Single ____ Divorce in process ____ Unmarried, living together

Length of time: ______Length of time:______

____ Legally married ____ Separated ____ Divorced

Length of time: ______Length of time: ______Length of time: ______

____ Widowed ____ Annulment

Length of time: ______Length of time: ______Total number of marriages: ___

Assessment of current relationship: ____ Good ____ Fair ____ Poor

Explain: ______

______

Development

Are there special, unusual, or traumatic circumstances that affected your childhood?

___Yes ___ No

If Yes, please describe:

Has there been history of child abuse? ____ Yes ____ No

If Yes, which type(s)? ____ Sexual ____ Physical ____ Verbal

If Yes, the abuse was as a: ____ Victim ____ Perpetrator

Other childhood issues: ______

______

Cultural/Ethnic

To which cultural or ethnic group, if any, do you belong?

Are you experiencing any problems due to cultural or ethnic issues? ____ Yes ____ No

If Yes, describe:

Spiritual/Religious

How important to you are spiritual matters? ____Not ____Little ____Moderate ____ Very Much

Are you affiliated with a spiritual or religious group? ____ Yes ____ No

If Yes, describe:

Legal

Current Status

Are you involved in any active cases (traffic, civil, criminal)? ____ Yes ____ No

If Yes, please describe and indicate the court and hearing/trial dates and charges:

Are you presently on probation or parole? ____ Yes ____ No

If Yes, please describe:

Past History

DWI, DUI, etc.: ____ Yes ____ No

Criminal involvement: ____ Yes ____ No

Civil involvement: ____ Yes ____ No

If you responded Yes to any of the above, please fill in the following information.

Charges Date Where (city) Results

______

______

Education

Fill in all that apply: Years of education: ____ Currently enrolled in school? ____ Yes____ No

____ High school grad/GED

____ Vocational: Number of years: ____ Graduated: ____ Yes ____ No Major: ______

____ College: Number of years: ____ Graduated: ____ Yes ____ No Major: ______

____ Graduate: Number of years: ____ Graduated: ____ Yes ____ No Major: ______

Other training:

Employment

Employment History:

Current employment status:

_____ Full Time _____ Part Time _____ Laid off _____ Retired _____ Disabled
_____ Homemaker _____ Student _____ Other (describe):