Restoration Counseling Services, LLC
INFORMATION/FORMS
/ RCS
/

1528 Peachtree Lane, Suite 104Cullman, AL35058 | 256-735-8152

Email: Web: restorationcounselingcullman.com

Thank you for choosing Restoration Counseling Services. We look forward to providing services to you.

In order to make the most of your first appointment, please come at least 15 minutes prior to your scheduled time. It is important that you bring the following items with you:

1)Completed paperwork

If you are unable to download or print forms, they will be available at the Welcome Desk in the waiting room.

2) Copayment and/or Deductible (amount not covered by insurance)

Insurance co-payments and deductibles are payable at the time of service. If you have a change to your insurance, you must notify us. Otherwise, you will be responsible for all unpaid claims.

3) Directions: 1528 Peachtree LaneCullman, AL35058. Your GPS should give you accurate directions.

- We are centrally located to Birmingham, Decatur, and Huntsville.

- The office is located on Peachtree Lane, off of HWY 31 N, behind the old Movie Factory and

Next to Classy Lady dress shop.

From Birmingham: Take I-65 North . Take exit #310 to Cullman/Moulton. Turn right onto HWY 157 at the exit. Turn left onto HWY 31 N @ the red light, Turn first road on right, onto Peachtree Lane.

From Huntsville/Decatur: Take I-565 West to I-65 South towards Birmingham. Take exit #310 to Cullman/Moulton. Turn right onto HWY 157 at the exit. Turn left onto HWY 31 N @ the red light, Turn first road on right, onto Peachtree Lane.

When you enter the office, please have a seat and we will be with you shortly.

How to contact RCS:The best way to contact us is through a phone call or text (256-735-8152) you may also email ()

We will reply within 24 hours, unless it is a holiday or weekend. If it is a true emergency, please call 911 or the Crisis Services of North Alabama at 256-716-4052. I do not take after hour calls.

IF BOTH YOU AND YOUR SPOUSE ARE ATTENDING, BOTH WILL NEED TO COMPLETE FORMS.

SECTION A

EVERYONE WILL NEED TO COMPLETE

SECTION B

ONLY COMPLETE, IF NOT COMPLETED ON LINE

SECTION C

ONLY COMPLETE, IF COUNSELING IS

FOR A CHILD OR TEEN (SECTION A & C)

Restoration Counseling Intake Form

SECTION A:

CONTACT INFORMATION
First Name: / MI: / Last Name:
Nick Name: / DOB: / SSN:
Address: / Age: / E‐Mail:
______
How often do you check your email?
Daily Weekly Monthly Rarely
Cell Phone: ______‐______‐______
May we Text/Call: Yes No / Home Phone: ______‐______‐______
May we call/leave message: Yes No / Work #: ______‐______‐______
May we call/leave message: Yes No
Relationship Status: ❏ Single ❏ In Relationship ❏ Married ❏ Separated ❏ Divorced
How long? ______
Partner’s Name (If Applicable):
Referred by?
EMERGENCY INFORMATION
Emergency Contact: / Emergency Contact Relation:
Phone:
BILLING INFORMATION
Primary Insured /Subscriber’s name: / Subscriber DOB:
Subscriber SS#:
Primary Insurance: / Insured’s Employer:
Insurance ID/Contract #:
Group/Plan # / Relationship to Subscriber:
Secondary Insurance:
Secondary Insured’s name: / Subscriber DOB:
Subscriber SS#
Secondary Insurance ID/Contract #
Group/Plan # / Insured’s Employer:
Relationship to Subscriber:
Authorization to Bill Insurance:
X______
Signature / Date:
______

Restoration Counseling Servivices, LLC

Authorization and Releases

•I authorize/ request my insurance company to pay directly to Restoration Counseling Services, LLC. I authorize the release of necessary information (diagnosis, reason for treatment, progress notes, and dates of service) to third party payers/insurance companies or EAP Providers.

•I understand that I am financially responsible for any balance. I also authorize Restoration Counseling Services, LLC or the insurance company to release any information required to process my claims.

•I have been informed of HIPPA guidelines and regulations related to the confidentiality of medical records. For your convenience, a copy of the HIPPA Notice of Privacy is located in the waiting room.

•I agree to be responsible for payments of all service (to include self-pay) rendered on my behalf or for my dependents.

•I agree to notify your office at least 24 business hours in advance, if I need to reschedule or cancel an appointment. Appointments can be canceled through email, text, or by phone. I acknowledge that a fee will be charged, which is not covered by my insurance benefits.

Late Cancel/No Show Charge: $50 Each occurance

______Signature of Client or Responsible Party Date

Confidentiality

I agree to maintain the confidentiality of those receiving care at Restoration Counseling Services, LLC in order to facilitate a safe and secure environment for treatment and health for others and myself.

As a client, visitor, guest, or student at Restoration Counseling Services, LLC, I understand that Federal Regulations on confidentiality require that I do not reveal the identity of any person I may see while at Restoration Counseling Services, LLC. I understand that any disclosure of patient information, including the person's presence in treatment, or description of any person without specific written consent from that person may be interpreted as a Federal Criminal Offense.

Confidentiality of Client Records

Federal law protects the confidentiality of client records maintained by this program. Generally, the program may not say to a person outside Restoration Counseling Services, LLC that a client attends the center, or disclose any information identifying a person as a client. Exceptions:

1.The client or parent of a minor signs a consent in writing.

2.The disclosure is allowed by a court order.

3.The disclosure is made due to a medical emergency.

4.The disclosure is about suspected child abuse or neglect.

5.The disclosure is regarding behavior that places the client or others in jeopardy while working in what the counselor can reasonably assume to be a safety sensitive position.

I have read and understand the limitations of confidentiality and release of information as explained and described in this statement.

______

Signature of client or Responsible Party Date

Consent to Treatment

I hereby grant permission for any counseling, counseling observation, or diagnostic evaluation that may be deemed pertinent by Restoration Counseling Services, LLC counselor. I understand that counseling sessions for my family, my marriage, or myself are strictly confidential.

______

Signature of client or Responsible Party Date

ONLY COMPLETE THIS SECTION, IF YOU DID NOT COMPLETE THIS INFORMATION ON-LINE.

SECTION B: Adult Biographical Information

If you are seeking counseling for a child or teen, please skip to section C.

Adult Biographical Questionnaire

**If you and your spouse are both coming for the session, each needs to complete a form.

Name: ______Age: ______Date: ______

Occupation: ______Work Hours: ______Education: ______

Overall job satisfaction: ______

The reason (s) I am seeking counseling?

How long has the current problems existed: ______

About Your Relationships

Please list your marriage(s) or other “significant other: relationships. Also list anyone that is living with you.

Spouse’s Name Married Duration of Name/Ages of Children

Yes/No Relationship

______

______

Family History

Mother’s age ______If deceased, how old where you? ______Cause of death: ______

Relationship:  good  fair poor close no contact other

Father’s age______If deceased, how old were you? ______Cause of death: ______

Relationship: good  fair poor close no contact other

If your parents are separated, how old were you then? ______

Number of Brothers/ages: ______Number of sister/ages: ______

Please indicate whether any of your (blood) relatives have had any of these concerns: If so what relationship to you.

SUICIDE/ALCOHOL/DRUG PROBLEMS/DEPRESSION/ANXITY/OTHER:

Mother, father, siblings; grandparents; aunts; uncles; cousins:

-Describe any current or past Legal issues: ______

-Describe any current or past alcohol/drug issues or treatment: ______

-Have you received counseling or seen a psychiatrist in the past: When? Who? Issues addressed? ______

______

-Are there any serious health problems/accidents/disabilities (current or past) that we should know about? ______

______

-Please list any medications you are currently taking: ______

-Have you ever been prescribed an antidepressant? ______

-My relationship with my family/spouse/significate other: ______

-My relationship with my children: ______

-Would you like spiritual/religious beliefs to be incorporated into your counseling? ______

-Have you ever served in the military? ______

-Did you ever serve in a combat zone while in the military? ______

SYMPTOM CHECK LIST

depression / anxiety / abuse / legal / Medical
appetite change / shame/guilt / emotional Abuse / work / Chronic pain
suicidal thoughts / panic attacks / self esteem / school / Hysterectomy
hopelessness / dizziness / trust / irresponsible / Diabetes
crying / nervous / weight / grief / Thyroid
confusion / stress / anger / unwanted / Seizures
low energy / perfectionist / aggressive / unmotivated / Heart
Increase sleep / Stomach pains / sexual issues / unattractive / Obesity
lack of sleep / headaches / alcohol / inferior / Fibromyalgia
memory / shakiness / drugs / moody / Hypertension
isolation / sweating / children / bored / Cancer
concentration / chest pains / no friends / lonely / Pregnancy
irritability / fears / jealous / alcohol use / Miscarriage(s)
Sadness / PTSD / dating / drug use / Other

RELATIONSHIP CHECK LIST

In-laws / divorce / sexual issues / unhappy / jealousy
parenting / separation / pornography / trust / controlling
family issues / emotional affair / on-line issues / decrease sex drive / work issues
physical abuse / sexual affair / chores / bored / social media
emotional Ab. / isolated / money / communication / health
aggressiveness / friends / religion / other / 

What I want to be different in my relationships/marriage?

What else would I like my Counselor to know?

Section C: CHILD/ADOLESCENT Biographical Information:

Questionnaire for Parents/Legal Guardian

Thank you for your time and effort in completing these forms. They provide very valuable information for therapy that helps provide excellence in the counseling process. Your information will be kept private and confidential. Thank you for choosing Restoration Counseling Services, LLC to assist you in this time of your life.

Person completing this form: / Date:
Relationship to child/adolescent:
Child’s Name: ☐M ☐F Age: DOB:
Please describe in detail, the concerns that prompted you to bring your child to therapy (including when the problem started and how often it occurs, and what stressors may contribute to the problem, etc.)
Has your child received any previous psychiatric or counseling treatment? ☐Yes ☐No If yes, please explain.
If yes, please include provider’s name and dates of services: Also list any medication your child/teen has been prescribed.
Please describe your goals or expectations for the counseling process:
Medical History
Name of Family Doctor: / Date last seen:
Name of Psychiatrist: / Date last seen:
Please check any of the following conditions for which your child was every evaluated or diagnosed:
☐Seizures / ☐Heart Problems / ☐Weight Problems / ☐Head Injury
☐Asthmatic condition / ☐Chronic Fatigue / ☐Chronic Headaches / ☐Depression
☐Hearing Loss / ☐Stomach Problems / ☐Allergies / ☐Anxiety/Panic
☐ADHD / ☐Learning Disability / ☐Other (explain):
Please explain any item that you checked:
TRAUMA HISTORY: Please circle any that your child has experienced.
Loss of a loved one Bullying Sexual abuse/molestation Witnessed violence
Divorce/separation Nightmare Physical Abuse Car Accident
Bedwetting Emotional Abuse

Please list anything else you wish to your child’s counselor to know: