Eli Ogburn, LCSW
Client Information
Date ______
Client Name ______
Name, if different, on insurance paperwork ______
Preferred Pronoun (she/he/they/etc.) ______Gender ______
SSN ______
Client Date of Birth ______Age ____
Race/Ethnicity ______Relationship Status ______
Are you employed? ______Occupation? ______
Address, Including Zip ______
Phone ______Okay to leave a message? _____
Email ______
Primary Healthcare Provider______Phone ______
Emergency Contact Name ______
Phone ______Relationship to Client ______
Annual Income ______# of Dependents ______
Insurer, if applicable ______Policy # ______
Current Concerns
What brings you to therapy at this time? ______
______
Do you currently ever have any thoughts about suicide? ______
Have you ever attempted suicide? ______Have you ever engaged in any self-harming behaviors (cutting/burning/hitting yourself)? ______
Have you ever had any thoughts about severely injuring/killing someone else? ______Do you have any plans currently to severely injure/kill someone else? ______
Please circle any of the following symptoms you currently experience:
AnxietyPanic attacksNightmares/FlashbacksSocial anxiety
Fear of leaving the house Easily startled Feeling always “on guard” Obsessions Compulsions Rapid thoughts Rapid speech Sadness
Loss of interest in things you usually enjoyIrritabilityCrying Hopelessness Feelings of guilt Thoughts of Worthlessness Low Energy
Difficulty concentratingSleeping More than Usual
Decreased Need for Sleep Euphoria (intense joy/excitement) Isolating
Decreased Appetite Unstable/chaotic relationships (including friendships)
Impulsive decisions/behaviors Chronic Feelings of Emptiness Mood Swings
Intense & Frequent Anger
Treatment History
Have you ever had therapy before? ______For what have you sought therapy previously? Please list dates, if known. ______
Have you ever been hospitalized for mental health reasons? ______
If yes, Hospital Name(s) ______Dates: ______
______
______
Diagnoses, if known ______
Are you currently on any medications for mental health symptoms? ______
NameDosageFor How Long Prescribed By
______
______
Substances/Medical History
What substances, if any, are you using currently? ______
If you drink alcohol, how often do you drink per week? ______Have you ever tried to cut back on your drinking? ______If so, were you able? ______
Have you ever been in treatment for substances? ___ Are you in recovery? ____
If in recovery, for how long? ______
Other substances & Frequency of Use ______
Do you consume caffeine?_____ If so, how much per day? ______
Do you have any chronic medical conditions or physical health challenges? ____
If so, please list______
Do you have an history of ever restricting your intake of food? ____ Of purging after you eat? ______
Social History
Who is important to you in your daily life?______
What do you enjoy doing? ______
If you are currently in (a) romantic/sexual relationship(s), for how long? ______
How do you identify your sexuality (queer/poly/heterosexual/bisexual/kink,etc.)? Use as many words as you like______
Who raised you growing up? ______Who do you identify as family? ______Do you have pets? ____ Who?______Have you ever been in any relationships (of any kind) that involved violence? ______
Is there a history of any mental health issues or substance abuse in your biological family, if known?____ If yes, please describe______
Policies and Procedures
Welcome. This policy and information sheet is meant to answer frequently asked questions regarding the process of therapy. Please read it carefully and feel free to ask questions. By signing this form, you are consenting to an agreement between us.
MY PRACTICE
I am a licensed clinical social worker licensed to practice in the state of North Carolina. My practice is informed by anti-oppression values. With each client I work to name and validate the effects various power structures have on our mental health and together find strategies to find our strength and work toward change. I work with each person using a range of modalities based on each individual’s therapy goals and will draw on your specific strengths in our work together. I can provide both longer and shorter term therapy modalities depending on your treatment needs.
For people seeking gender-affirming therapy, I operate using an informed consent model, which means that I support all people’s bodily autonomy and right to identify their gender however they choose and to pursue access to transition. I offer gender-affirming therapies to help ensure that people have coping skills and support around their gender identity, not to make people prove that they are who they say they are.
I do not prescribe medications, but if during treatment we discover that medications could be a helpful addition to your treatment, we will work together to find someone who can prescribe medications for you.
Our initial meeting will be an intake that lasts approximately 50-60 minutes. Future sessions will be the standard “therapy hour” of 50 minutes in length. At the intake session, we will review your ‘client information’ paperwork, and I will ask you further questions to find out more about you, why you are seeking treatment, and about your therapy goals. This is also a chance for you to get a feel for me and whether you think we may be a good match together. At the intake and following session, I will be able to offer you an idea of what I think our work together might look like. You can always ask any questions about your treatment that you may have. You then get to choose whether or not you want to work with me. Choosing a therapist who is a good match for you is important.
We will have check-ins about how our work together is going and work together to determine when your therapy will terminate based on reviews of your progress and goals. I also reserve the right to terminate our treatment if I think that that this signed agreement is not being honored, for nonpayment for services, or if another clinician would be better suited to help you with your goals. If I terminate our treatment, I will offer you a referral, or you may work with your med prescriber or primary care provider to find an appropriate referral.
BENEFITS AND RISKS
Therapy can be hard and extremely rewarding work. Participating in therapy can have benefits and risks. Ongoing therapy can result in a number of benefits, including reduction of suffering, improved interpersonal relationships, increased self-esteem, and insight. However, there are no guarantees that therapy will result in positive or intended results. There are risks in undertaking therapy. Some of the information discussed in the course of therapy may be distressing, but may be necessary to help resolve presenting concerns. As a result, you may at times experience difficult emotions like sadness, guilt, anxiety, anger or frustration. Often in therapy, people experience an increase in these emotions before noticing that their suffering has decreased.
CONTACT INFORMATION
If you need to leave a message, please call (919)322-9355. If your message is not urgent, you can email me at . Please do not send any urgent messages to me by email as I may not check it in a timely manner. If you choose to email me please consider that email is capable of being intercepted, so any information shared via email cannot have its privacy guaranteed. By requesting an emailed response, you are acknowledging that you are aware of the risks to your privacy and indicating that you will take responsibility for any related consequences.
FINANCIAL AGREEMENT
My fee is $100 per 50-minute session, due at time of appointment. I accept cash, check, and debit/credit cards. A $20 fee will be charged to you for any returned check. A sliding fee scale option is available for those with a limited ability to pay. When using insurance, I ask that you find out your co-pay based on in- or out-of-network and you are ultimately responsible for payment if not reimbursed by insurance. I am in-network with Blue Cross Blue Shield of NC and out-of-network with other insurance panels. If requested I will provide you with a detailed bill that you can send to the insurer. You will be responsible for determining insurance coverage and for any fees not covered by insurance. Please keep in mind that when billing insurance, I am required by the insurance company to disclose clinical diagnoses and sometimes additional clinical treatment information or possibly your entire clinical record. You may choose not to bill your insurance if you do not wish for this information to be disclosed to your insurance company.
CANCELLATIONS
If you are unable to keep a scheduled appointment, you must contact me by phone at least 24 hours notice to allow time to fill the appointment. My full fee will be charged for appointments cancelled with less than 24 hours notice. Please be aware that insurance cannot be billed for missed sessions. This charge may be waived or reduced in some extreme instances and we will decide together if your situation warrants that. If you do not keep two appointments in a row, and I don’t hear from you, I will not continue to reserve a time in my schedule for you. You are always welcome to contact me about resuming therapy.
PHONE COMMUNICATION
I generally return phone calls within 24 hours during the week. I return urgent phone calls on weekends, but return more routine weekend calls on Monday.
SOCIAL MEDIA
I will not accept any friend requests on Facebook or any other forms of social media either during or after our treatment together has ended. This policy is because I value and protect the clinical nature of our relationship. Furthermore, I cannot guarantee your privacy on any form of social media, and this is not a secure form of communication. I do not search for client’s personal Facebook or other social media pages EXCEPT in VERY rare situations such as if I have reason to believe you are in danger and cannot reach you or your emergency contact by phone, I may use an engine search to try to get in touch with you. This is EXTREMELY rare, and if it ever happens, I will disclose and discuss this with you at our next session.
EMERGENCY COVERAGE
All emergencies should be handled by the nearest hospital emergency room if you are unable to reach me directly.
CONFIDENTIALITY POLICY AND EXCEPTIONS
Your privacy is extremely important to me. In addition, state and federal laws as well as my professional ethics protect it. I will never reveal anything about your treatment, diagnosis, history, or even that you have meet with me professionally, unless you provide written consent for me to do so.
There are some rare situations when I am required to breach confidentiality. I must report serious, current abuse of a minor or dependent adult. I am also required to report when a minor has disclosed to me that they have witnessed domestic violence. If I believe that you are in imminent danger of seriously harming yourself or someone else, I must take steps to prevent either from occurring. This may include informing law enforcement, warning the intended victim or arranging for hospitalization. I may have to disclose your personal health information (PHI) if I am ordered by a court to do so. If you experience a psychiatric emergency, I will disclose your PHI to other licensed health providers to the extent necessary to access appropriate care for you. Lastly, I may disclose relevant client information if a legal complaint is brought against me by a client.
If you have questions, please let me know. I will always be willing to discuss these and other issues with you.
CLIENT RECORDS
I am required by my professional ethics and laws to maintain client records. At any time, you have the right to ask for copies of these records. However, because records can be upsetting or confusing, I ask that you read them with me present so that we can discuss. If you request copies of your records, I will charge you for the cost of the copies.
RELEASE OF INFORMATION
In order to provide the most effective treatment for you, I will ask you to give me permission to communicate with any other mental health providers you may see (psychiatrist, nurse practitioner, MD). If you agree, I will ask for your written permission to make this contact.
CONSENT TO TREATMENT
I have received and agree to the office policies and have had the opportunity to ask questions. I consent to treatment with Eli Ogburn, MSW, LCSW.
Printed Name: ______
Signature:______Date:______
______