Ozmer Counseling, PLLC ~Courtney Ozmer, MEd, LPC 1333 McDermott Drive, Suite 200 Allen, TX 75013 (972) 984-6392
ADULT CLIENT INTAKE
Name of Client
Date of Birth Age Sex Race Religion
Street Address City Zip Code
May we contact you by mail at this address? YesNo
Email May we contact you by email? YesNo
Home PhoneMay we contact you and leave messages at home? Yes No
Cell Phone May we contact you on and leave messages on your cell? YesNo
Employer Work Phone
Job Title Education (years completed)
May we contact you and leave messages at work? YesNo
Marital Status (Circle): Single / Engaged / Married / Separated / Divorced / Widowed / Cohabitating
Date of current marriage/separation
Previously married? YesNoIf yes, when? How long?
Spouse Information (if applicable)
Name of Spouse Number of years married
Date of Birth Age Sex Race Religion
Child(ren)’s Name(s) Date of Birth Male Female
Date of Birth Male Female
Date of Birth Male Female
Date of Birth Male Female
Who is currently living in your household?
REASONS FOR SEEKING COUNSELING
What brought you to counseling? Please list your concerns in order of importance
When did your present concerns begin to be a problem for you?
What do you hope to gain from counseling?
Please indicate which of the following areas are currently problems for you. Check all that apply:
_____ Feeling inferior to others _____ Not being able to say what you really think or feel
_____ Under too much pressure and feeling stressed_____ Angry outbursts
_____ Feeling down or unhappy/depressed mood_____ Excessive fear of specific places or objects
_____ Work stressors_____ Difficulty making or keeping friends
_____ Loneliness _____ Concerns about finances
_____ Suspicious feelings toward others_____ Feeling as if you’d be better off dead
_____ Angry feelings_____ Difficulty making decisions
_____ Feeling “numb” or cut off from emotions_____ Loss of interest in sexual relationships
_____ Concerns about physical health_____ Concerns about emotional health/stability
_____ Hallucinations_____ Insomnia/difficulty sleeping
_____ Hypersomnia (sleeping all the time)_____Crying Spells
_____ Change in appetite (increase or decrease)_____ Uncontrollable anxiety or worry
_____ Loss of interest in usual activities/lack of motivation_____Lacking self-confidence
_____ Inability to control thoughts_____ Obsessions or compulsions with specific activities
_____ Hearing voices_____ Eating disorder
_____ Relationship difficulties_____ Excessive use of alcohol
_____ Drug abuse_____ Difficulty concentrating
_____ Nightmares_____ Mood shifts
_____ Elevated mood_____ Blackouts/temporary loss of memory
_____ Tremors_____ Delusion
_____ Cutting or other self-harming behaviors_____ Dizziness
_____ History of physical/emotional/sexual abuse_____ Concerns regarding family of origin
_____ Other (Please specify)
Who referred you to counseling? Referral Date
How did you find me?
COUNSELING AND PSYCHIATRIC HISTORY
Have you had previous counseling? Yes No
If yes, where and with regard to what concerns?
Have you ever been diagnosed with or treated for any type of mental illness? Yes No
If yes, which one?
Has anyone in your family ever been diagnosed or treated for any type of mental illness? Yes No
If yes, which one?
Physician’s Name Phone Number:
Address CityState Zip
How would you rate your current physical health? (circle one) Excellent Good Fair Poor
Are you currently experiencing any physical problems (headaches, body aches, stomach problems, etc.)Yes No
If yes, please explain:
Please list any medical conditions or disabilities:MEDICATION(S)
over-the-counter or prescription / DOSAGE / PRESCRIBING PHYSICIAN
EMERGENCY CONTACT (NEXT OF KIN – OTHER THAN SPOUSE)
Home Phone Work Phone Cell Phone
Address City, State, Zip
PROFESSIONAL DISCLOSURE STATEMENT
Therapy Policies and Services
Welcome! I am committed to providing you with quality mental health care. This information packet is intended to acquaint you with what you can expect in therapy and to address some of the typical areas of concern, especially for the first-time client.
Qualifications: Courtney earned a Bachelor of Science at Southern Methodist University where she majored in psychology. She then continued her education at the University of North Texas where she earned a Master’s degree in counselor education. Courtney is qualified to counsel according to the Texas Department of Health.
Counseling Relationship: While working together, our sessions may be very intimate psychologically, but our relationship is professional, not social. Please do not invite me to social gatherings, offer me gifts, ask me to write a reference for you, or ask us to relate to you in any way other than the professional context of our counseling sessions. You will be best served if our sessions concentrate exclusively on your concerns. Our in-person contact will be limited to counseling sessions you arrange with me. You may leave a voicemail for me at (972) 984-6392 and I will return your call as soon as possible. If you experience a mental health emergency, obtain crisis services by calling 911 and/or by going to a nearby hospital emergency room.
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 self. 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: Some clients achieve their goals in only a few counseling sessions; 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 you participate in a termination session. You also have the right to refuse or discuss modification of any of my counseling techniques or suggestions you believe might be harmful.
I assure you 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 not able to resolve your concerns, you may report your complaints to the Texas Department of Health, (512) 834-6658.
Conditions of Ongoing Counseling: If you have been in counseling or psychotherapy during the past seven years, I may request for you to sign a release so I may communicate with and/or receive copies of records from the professional(s) from whom you received mental health services. While you are in counseling with me, you agree not to establish or maintain a professional relationship with another mental health professional unless you first discuss it with me and sign a release permitting me to communicate with the other mental health professional(s). If you decide to establish or maintain a professional relationship with another mental health professional against my advice, I may consider this your decision to change counselors and reserve the right to terminate your counseling.
I also reserve the right to postpone and/or terminate counseling of clients who come to session under the influence of alcohol or drugs. In addition, I reserve the right to terminate counseling of clients who do not comply with the medication recommendations of their psychiatrist or physician.
Referrals: I recognize not all conditions presented by clients are appropriate for the treatment I provide. For this reason, you and/or I may believe a referral is necessary. In that case, I will provide some alternatives including programs and/or people who may be available to assist you. A verbal exploration of alternatives to counseling will also be made available upon request. You will be responsible for contacting and evaluating these referrals and/or alternatives. Certain aspects of treatment may require evaluation through psychological testing or medication. In such cases, a referral to a psychiatrist/medical doctor may be made. Ongoing dialogue with these professionals would be maintained to effectively manage the counseling process.
Fees: In return for a standard fee of $100 per 50-minute session, I agree to provide counseling services for you; however, other payment options are available upon request. Cash, personal checks made out to “Ozmer Counseling, PLLC,” or credit cards are acceptable forms of payment which is due at the beginning of each session. There is a $25 returned check fee. By consenting to treatment, you agree to pay counseling fees at the time of service.
Some insurance companies may cover part of this cost. You will be given a receipt at the end of your session for use in filing insurance claims. Please contact your insurance company to determine whether your insurance will reimburse you and what schedule of reimbursement will be used. I will provide you with a form containing questions which may be helpful in obtaining this information from your insurance company.
Health insurance companies often require that I diagnose your mental health and indicate that you have an “illness” before they will agree to reimburse you. In the event that a diagnosis is required, I will inform you of the diagnosis I plan to render before I submit it to your insurance company. Any diagnosis made may become a part of your permanent insurance records.
If you become involved in litigation that requires my participation (even if a subpoena is sent from the opposing counsel), and due to the complexity and difficulties involved with legal involvement, I will charge $250 per hour for preparation for and/or attendance at any legal proceedings.
CANCELLATION: If you need to cancel an appointment, 24 hours notice is required. If you miss an appointment without providing 24 hours notice, you WILL BE CHARGED $50. Missed appointments CANNOT be filed with insurance.
Records and Confidentiality: All of your communication becomes part of the clinical record. Adult client records are disposed of seven years after the file is closed. Most of our communication is confidential, however; I reserve the right to disclose confidential information if: a) I determine you are a danger to yourself or someone else; b)You disclose abuse, neglect, or exploitation of a child, an elderly, or disabled person; c) You disclose sexual contact with another mental health professional; d) I am ordered by a court to disclose information; e) You consent for me to release your records; or f) I am otherwise required by law to disclose information. If I see you in public, I will protect your confidentiality by acknowledging you only if you approach me first.
HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ AND REVIEW IT CAREFULLY.
Effective August 1, 2010
Use and disclosure of protected health information for the purposes of providing professional counseling services is sometimes required. Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes. Please read and initial each statement below:
Treatment: Use and disclose health information to:
Provide, manage, or coordinate care to consultants, referral sources, or physicians
Consult with other mental health professional(s) using client’s first name only to ensure confidentiality and provide client with the best care possible
As patient gives permission via “Informed Consent” form
Healthcare Operations: Use and disclose health information for:
Review of treatment procedures
Review of business activities
Staff training and care within our practice
Compliance and licensing activities
Other Uses and Disclosures without Your Consent
As required by law
Right to request where we contact you:
- Homeyes no
- Cell yesno
- Emailyes no
- Street Address yesno
- If none of the above, how may we contact you
(Initial here) I have read and signed the professional disclosure statement. I agree to pay counseling fees at the time of service and understand the cancellation policy.
By signing below, you attest that you have read and been made aware of your rights to confidentiality as a mental health consumer. Full HIPAA Compliance Rules and Regulations are posted in the counselor’s office at all times and may be read by the consumer or copied for the consumer upon request.
Client Printed NameClient SignatureDate Signed