Memorial Area Counseling

14133 Memorial Drive, Suite #4

Houston, TX 77079

Personal Information(couples should complete individual paperwork):

Date of Initial Assessment: ______

Client age: ______Client Name: ______

Spouse age: ______Spouse Name: ______

If minor, parent name: ______

Address: ______Zip: ______

Phone: ______

Text: ______I consent to receive text communication ______initial

Private e-mail: ______I consent to receive e-mail communication ______initial

___ Married ___ Divorced ___ Separated ___ Single ___ In a relationship

Children (ages): ______

Who lives in your household (names & ages):

______

Employment (What do you do for a living): ______

Spouse’s Employment: ______

Medications you are currently taking: ______

Are you seeing a psychiatrist? ___ Yes ___ No Have you ever seen a therapist? ___Yes ___ No

Who referred you? ______

Relevant Health Information that impacts mood or mental health? ______

Current Life Stressors: ______

Family history of: ___ alcoholism ___ substance abuse ___ physical abuse ___ sexual abuse

___ depression ___ anxiety ___ other mental health disorders ___ trauma

Courtney Miller, M.A., LPC Intern

Supervised by: Sally James, M.A., LPC-S, N.C.C.

PROFESSIONAL DISCLOSURE STATEMENT

QUALIFICATIONS: I am a Licensed Professional Counselor Intern in the state of Texas working towards full licensure. I earned my Bachelor’s degree in 2001 from The University of Texas at Austin in Engineering Route to Business (Electrical Engineering and Marketing concentrations) and my Master’s degree in Clinical/Counseling Psychology from La Salle University in 2006.

EXPERIENCE: During my years of experience, I have worked with every age group in a variety of settings – crisis intervention, community mental health, partial hospitalization, intensive outpatient, and inpatient. I currently work with adolescents, adults, families, and couples dealing with a wide variety of emotional, behavioral, and relational issues.

NATURE OF COUNSELING: My approach to counseling comes from a client-centered and solution-focused perspective. I also utilize methods from Cognitive-Behavioral Therapy, Schema Therapy, and Pragmatic/Experiential Therapy for Couples. The aim of counseling is to reach specific goals for individual and relational growth, which are mutually agreed upon by both the client and the counselor. I believe that my fundamental role as a counselor is to provide you with a safe place to be truly heard, to help you gain insight into yourself, and to teach you new strategies to improve your life. This will be achieved through a combination of exercises, homework, readings, and the therapeutic relationship.

INFORMED CONSENT

COUNSELING RELATIONSHIP: During the time that we work together, we will meet at a mutually agreed upon frequency for approximately 60-minute or 90-minute sessions. It is important to remember that our relationship is strictly professional, and not social. Our contact will be limited to counseling session that you arrange. Our policy and that of the professional counselor ethics prohibit the receipt of gifts valued more than $50 by counselors by clients.

EFFECTS OF COUNSELING: At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discontinuing counseling. While benefits are expected from counseling, specific results are not guaranteed. Counseling is a personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Some of these changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achieve the best possible results for you.

CLIENT RIGHTS AND RESPONSIBITIES: Some clients need only a few counseling sessions to achieve their goals; others may require months or even years of counseling. As a client, you are in complete control and may end our counseling relationship at any time, though I do ask that you participate in a terminations session. You also have the right to refuse or discuss modification of any of my counseling techniques or suggestions that you believe might be harmful. You agree to come to counseling free from the influence of drugs, including alcohol. I assure you that my services will be rendered in a professional manner consistent with accepted legal and ethical standards. If at any time, for any reason, you are dissatisfied with my services, please let me know. If I am unable to resolve your concerns, you may refer your complaints to Sally James, my supervisor, at (281)536-9223 or you may contact:

Texas State Board of Examiners of Professional Counselors
Texas Department of State Health Services
Mail Code 1982
P.O. Box 149347
Austin , Texas 78714-9347

E-mail:
Telephone: (512) 834-6658

REFERRALS: Should you and/or I believe that a referral is needed, I will provide some alternatives, including programs and/or people who may be available to assist you. You will be responsible for contacting and evaluating those referrals and/or alternatives.

FEES: Services will be provided for a fee of $110 per 60-minute session and $170 per 90-minute session. The fee for each session will be due at, and must be paid by, the conclusion of each session. Cash, credit, debit cards, or personal checks made out to “Gina Watson, LMFT” are acceptable for payment. Memorial Area Counseling does not file for reimbursement from health insurance companies.

CLIENT NO-SHOW/LATE CANCELLATION: When you have an appointment, I reserve that time for you and make it unavailable to any other client. If you cancel or reschedule an appointment, it is very rare that I am able to fill that slot with another client when less than 3 to 4 days’ notice is given. Because Memorial Area Counseling is a small private practice, the cancellation policy is integral to business. It is understood that you may need to reschedule in the event of an emergency. However, if you must cancel or reschedule due to an emergency, please provide me with at least 48 hours’ notice in order to avoid paying for the full session fee. Appointments are a purchase of “time” and clients who fail to show up for an appointment, cancel, or reschedule with insufficient notice will be charged accordingly. I am tremendously grateful for your understanding regarding this important issue.

RECORDS AND CONFIDENTIALITY: The law requires me to protect the privacy of your health information. This means that I will not use or let other people see your health information without your permission except in the ways I tell you in this notice. I will safeguard your health information and keep it private. This protection applies to all health information I have about you, no matter when or where you sought services. When you are in my office, I will not allow any unauthorized person to interview, photograph or record you without your written permission. I will not tell anyone if you sought, are receiving, or have ever received services from me unless the law allows me to disclose that information. If I see you in public outside of my office, I will not approach you or act as if I recognize you. Most of our communication is confidential, but the following limitations and exceptions do exist:

  1. If I determine you are a danger to yourself or someone else;
  2. You disclose abuse, neglect, or exploitation of a child, elderly, or disabled person;
  3. You disclose sexual contact with another mental health professional or clergy;
  4. I am ordered by the court to disclose information;
  5. You direct me to release your records; or
  6. I am otherwise required by law to disclose information

All of our communication becomes part of the clinical record. Records are the property of Memorial Area Counseling. All client records are disposed of 5 years after the file is closed; this applies to both adult and minor clients. In the event of my death or incapacity, or the termination of my counseling practice, the custody and control of your records will be given to Gina Watson, LMFT.

CONTACTING US: We answer our main office number 8:00 AM – 5:00 PM Monday through Friday (except holidays). You may have my cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email and text messaging are not secure mediums in terms of privacy and confidentiality, so our policy regarding electronic communication and cell phone use includes the following:

  • We do not provide therapy/counseling via email or text messaging.
  • Text messaging and email will be used for administrative tasks only (as defined above).
  • I may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails.
  • If your therapist leaves for an extended period of time you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence.

EMERGENCIES

  • Ifyouhaveanemergencydonot contact me via my cellphone–thisisnot monitored regularly.
  • Ifyouhaveanemergencydonotcontact me via email – this is notmonitored regularly.
  • If you have an emergency do not contact Memorial Area Counseling’s main number – this is not monitored regularly.
  • Ifyouhaveanemergencygototheemergencyroomnearestyouorcall911.

COUNSELING VIA TECHNOLOGY: Online methods of providing counseling services are evolving all of the time. At Memorial Area Counseling, we will utilize those means ethically and therapeutically. Technology-assisted distance counseling for individuals, couples, and groups involves the use of the telephone or the computer to enable counselors and clients to communicate at a distance when circumstances make this approach necessary or convenient. Tele-counseling involves synchronous distance interaction among counselors and clients using one-to-one or conferencing features of the telephone to communicate. Video-based individual Internet counseling involves synchronous distance interaction between counselor and client using what is seen and heard via video to communicate. In order to utilize technology for therapy, you must (adapted from the NBCC code of ethics for technology based counseling):

  1. Be an established client with intake paperwork, payment information, and an emergency contact/face sheet on file with Memorial Area Counseling.
  2. Be within the state of Texas, unless

a)You are a resident of Texas but you are temporarily located outside of the state.

b)You are a client newly relocated outside of Texas and you experience an emergency. In this case your therapist will provide triage and referrals to a local counselor in your state.

c)You are located on a US military base.

  1. Have a release of information for an emergency contact for the location from which you will be calling.
  2. Assume responsibility for securing a location to speak with the therapist that is confidential.
  3. Understand when communicating via technology, confidentiality cannot always be guaranteed. By engaging in counseling via technology you acknowledge that risk and hold Memorial Area Counseling harmless
  4. Agree to an alternate form of communication in case technology fails during the counseling session. If technology fails less than 30 minutes into a counseling session and communication cannot be reestablished, you can reschedule at no charge for the remainder of the missed session. If technology fails over 30 minutes into the session and technology cannot be reestablished, you will be charged for the entire session.

ACKNOWLEDGMENT AND CONSENT: By your signature below, you are indicating that you have read and understood this statement, or that any questions you had about this statement were answered to your satisfaction, and that you were furnished a copy of this statement.

By my signature, I verify the accuracy of this statement and acknowledge my commitment to conform to its specifications.

Client’s Signature ______Date______

Counselor’s Signature______Date______

PERMISSION TO PROVIDE

MENTAL HEALTH/COUNSELING SERVICES TO A MINOR

By my signature below, I verify that I am the parent and/or legal guardian of the minor child

______DOB______and have the legal authority to seek mental health and counseling services for him/her. I hereby grant:

Courtney Miller, M.A., LPC-Intern

permission to provide these services for my child. I further understand that according to the Texas law both parents have equal access to all medical and mental health records of a minor child, unless specifically prohibited by law. Therefore, all medical and mental health records will be released upon request to a legal parent, guardian, or authorized representative of this minor child. I understand that Memorial Area Counseling does not provide a forensic evaluation. I understand that Memorial Area Counseling does not make recommendations about placement of a child for custody disputes and does not provide investigation or reassessment to reach a determination about child abuse or custody.

If there is a minor child with divorced or separated parents, a certified copy of the temporary orders or divorce decree must be provided prior to the therapist beginning treatment.

Signature: ______Date: ______

Print Name: ______

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