A HEALING ALTERNATIVE COUNELING AND WELLNESS CENTER, LLC
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- Kory Sutton
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1 A HEALING ALTERNATIVE COUNELING AND WELLNESS CENTER, LLC 8603 CROWNHILLE SUITE 29 SAN ANTONIO, TX PHONE: (210) FAX: (210) Hey there, new person! Enclosed in this packet is all the basic forms you will need to complete before your first in-office appointment. Paperwork can absolutely be completed during your first appointment, though many people prefer it all completed ahead of time. It can be printed and brought in the day of your appointment or ed or faxed to me before the appointment time. Copies of my HIPPA policy and my Social Media Policy are available as separate downloads and should be read before completing this packet. Additionally, I keep printed copies of them in the office and can provide them to you at your request. There are other forms available on my website that you may need to complete such as a consent to release information if you are working with other treatment providers. Please have each person who is entering services complete a packet. (Though don t freak out by the counseling contract if you are attending as a couple or family unit you will only pay for the service visit, not per person!) If you have any questions, do not hesitate to contact me at info@faithgharper.com Faith G. Harper.
2 Faith G. Harper, PhD, LPC-S, ACS, ACN A Healing Alternative Counseling and Wellness Center, LLC info@faithgharper.com Phone: (210) Fax: (210) Counseling Contract Counseling is most helpful when it takes place in a framework of trust, clarity, and understanding. This contract is intended to clarify and help this relationship. Should you have any questions concerning this covenant, please discuss them with me. Financial Understanding I/we understand that the fee for a 50 minute session is $135.00; this fee is the same for an initial visit. I have discussed this amount with the therapist along with my ability to pay. I agree to a fee in the amount of. If I choose to use my insurance benefits to offset the cost of my therapy, then I understand that the full fee will be charged. I agree to be responsible for that full fee amount. Cancellation Policy I understand that I will be charged the full fee of $ for a missed appointment or if I fail to cancel without 24 hours notification. This can be discussed with your therapist if special circumstances result in a missed appointment. Limits of Confidentiality I understand that while confidentiality is central to the process of therapy, it must be broken and a report made to the proper authorities when there is abuse or neglect of children, disabled persons, and the elderly; when there is intent to harm oneself, another, or property; or when a court order is issued. Terminating Therapy I understand that though I may stop therapy at any time, the ending of therapy is best if discussed with my therapist at least one session before it ends. Consent to Counseling I understand that there are certain risks in therapy and that there may be alternatives to therapy. I agree to counseling with Faith G. Harper. These services may also include group therapy, psychoeducation, assessment and diagnostic impressions, and referrals for other needed services. Signed Printed Name Date
3 Faith G. Harper, PhD, LPC-S A Healing Alternative Counseling and Wellness Center, LLC info@faithgharper.com Phone: (210) Fax: (210) CONTACT INFORMATION Today s Date Reverified Date Reverified Date Legal Name Last First MI Preferred Name DOB / / Legally Authorized Representative (if applicable) Last First MI Local Address Street Apt# City, State, Zip Preferred Form of Contact? Phone Cell Phone Text Cell Phone If Phone Contact checked, OK to leave message? Home Phone If Phone Contact checked, OK to leave message? address: If you marked that you prefer contact or text contact, please note the following: I understand that the confidentiality of information transmitted via or text cannot be guaranteed. Your Initials In Case of Emergency, Notify: Name First Last Relationship Contact info: Street Apt# City, State, Zip Home Phone Cell Phone
4 Faith G. Harper, PhD, LPC-S A Healing Alternative Counseling and Wellness Center, LLC info@faithgharper.com Phone: (210) Fax: (210) Counseling Contract Counseling is most helpful when it takes place in a framework of trust, clarity, and understanding. This contract is intended to clarify and help this relationship. Should you have any questions concerning this covenant, please discuss them with me. Financial Understanding I/we understand that the fee for a 50 minute session is $135.00; this fee is the same for an initial visit. I have discussed this amount with the therapist along with my ability to pay. I agree to a fee in the amount of. If I choose to use my insurance benefits to offset the cost of my therapy, then I understand that the full fee will be charged. I agree to be responsible for that full fee amount. Cancellation Policy I understand that I will be charged the full fee of $ for a missed appointment or if I fail to cancel without 24 hours notification. This can be discussed with your therapist if special circumstances result in a missed appointment. Limits of Confidentiality I understand that while confidentiality is central to the process of therapy, it must be broken and a report made to the proper authorities when there is abuse or neglect of children, disabled persons, and the elderly; when there is intent to harm oneself, another, or property; or when a court order is issued. Terminating Therapy I understand that though I may stop therapy at any time, the ending of therapy is best if discussed with my therapist at least one session before it ends. Consent to Counseling I understand that there are certain risks in therapy and that there may be alternatives to therapy. I agree to counseling with Faith G. Harper. These services may also include group therapy, psychoeducation, assessment and diagnostic impressions, and referrals for other needed services. Signed Witness Date Signed Witness Date
5 Receipt of Notice of Privacy Practices Form A Healing Alternative Counseling and Wellness Center, LLC Faith G. Harper, PhD, LPC-S I,, hereby acknowledge receipt of the NOTICE OF PRIVACY PRACTICES from my therapist. The NOTICE OF PRIVACY PRACTICE provides detailed information about how the practice may use and disclose my confidential information. I understand that my therapist has reserved a right to change his or her privacy practices that are described in the NOTICE. I also understand that a copy of any Revised NOTICE will be provided to me or made available. CLIENT SIGNATURE DATE
6 Faith G. Harper, PhD, LPC-S A Healing Alternative Counseling and Wellness Center, LLC info@faithgharper.com Phone: (210) Fax: (210) Social Media Acknowledgement Form I acknowledge that I have been provided a copy of Faith Harper s social media policy which remains in effect even when I am no longer receiving services from her. I understand that this policy is available for download and review at any time from her website ( and updates in this policy will be discussed with me, if I am currently receiving services from her. I understand that if any questions about social media arise are best discussed directly with her during our sessions. Client Name: Client Signature: Date: Counselor Signature: Date:
7 Life History Questionnaire FAITH G. HARPER, PhD, LPC-S, ACS, ACN The purpose of this questionnaire is to obtain some information regarding the issues that bring you in today, as well as some of your experiences and background. Completing these questions as fully and as accurately as possible will benefit you through the development of a treatment plan suited to your specific needs. Name: Date: Address: Home Phone: ( ) Cell Phone:( ) Address: DOB: / / Age: Occupation: SIGNIFICANT RELATIONSHIP STATUS: Single Engaged Married Separated Divorced Widowed Committed Relationship LIST ANY MEDICATIONS YOU ARE TAKING: Name Dosage Prescribed for PLEASE STATE WHAT BRINGS YOU IN: HOW LONG HAS THIS BEEN OCCURRING?
8 On the scale below, please circle the severity: mildly upsetting incapacitating ALCOHOL AND OTHER DRUG USE Please tell me about your use of alcohol and other substances: Never Seldom I drink 4 or more drinks in a 24-hr period. I have missed work/school due to drinking. After drinking, I have forgotten where I was or what I did. I use other recreational drugs*. I have missed work/school due to recreational drugs*. Once a month 2-3 times a month Weekly Daily After using recreational drugs*, I have forgotten where I was or what I did. *RECREATIONAL DRUGS INCLUDE, among others: marijuana; cocaine; ecstasy; heroin; meth; as well as any prescription or over-the-counter drugs taken for recreational purposes. PREVIOUS MENTAL HEALTH TREATMENT: Please list any psychiatrists, therapists, hospitals, self-help groups, and residential treatment centers, and the issues for which you were seen. FAMILY MENTAL HEALTH HISTORY Clinical Diagnosis Depression Bipolar Disorder Anxiety/Panic Disorder Eating Disorder ADD/ADHD (Attention Deficit) Post-traumatic Stress Disorder Obsessive-Compulsive Disorder Borderline Personality Disorder Schizophrenia or Psychosis Alcohol or Other Substance Abuse If YES, please check the box for all applicable family members NO Aunts/ Grand- Mother Father Brothers Sisters Cousins ONE Uncles parents Successfully Treated? Yes No Other family mental health information: Please describe any illness, loss, accident, or hospitalization that had a big impact on your life, and give the dates of their occurrences Do you have any major health concerns?
9 CURRENT & PREVIOUS SYMPTOMS/BEHAVIORS/EXPERIENCES NOW PAST NOW PAST DISTRESSING SYMPTOMS WORK/ACADEMIC CONCERNS Stress Procrastination Anxiety/nervousness Time management Panic attacks Poor performance evaluations/grades Perfectionism Test, speech, or performance anxiety Fearfulness/paranoia Conflict with a colleague, boss, or professor/teacher Obsessive thoughts BODY IMAGE AND FOOD USE Compulsions/rituals Binge eating Depression Purging (vomiting) Difficulty concentrating Laxative use/abuse Motivation problems Diet pill use/abuse Difficulty falling asleep Restricting food intake or avoiding food/fasting Difficulty staying asleep Overeating Loss of appetite Dieting Excessive crying Being overweight or underweight Irritability/anger/hostility Excessive exercise Mania (overly energized with unusual thoughts or behaviors) ADDICTION/DEPENDENCE CONCERNS Suicidal feelings/thoughts Alcohol addiction/dependence/overuse/abuse Suicide attempt(s) Drug addiction/dependence/overuse/abuse ROMANTIC RELATIONSHIP CONCERNS Prescription drug addiction/dependence/overuse/abuse Dating concerns Smoking/tobacco use Concerns about sex Gambling Conflict with partner/spouse Excessive internet use Break-up/end of romantic relationship Sexual addiction SOCIAL RELATIONSHIP CONCERNS CONCERNS INVOLVING VIOLENCE Difficulty making friends Unwanted sex Loneliness Being stalked Social anxiety Intimate relationship violence Conflict with friend(s) Problems with anger control GENDER/SEXUAL ORIENTATION CONCERNS Participant in a violent incident Gender identity or gender issues or questions Lesbian/gay/bisexual issues or orientation questions Witness of a violent incident Perpetrator of abuse (physical/sexual/psychological) Asexual/Demisexual/Greysexual issues or questions Survivor of abuse (physical/sexual/psychological)
10 HOME AND FAMILY EXPERIENCES Did the following occur in your family/home environment? Yes No Not Sure Parents divorced or permanently separated Frequent, hostile arguing among family members Death of a parent or sibling Parent(s) or sibling(s) with a drinking or drug problem Family member with an eating problem Family member with a debilitating illness, injury, or disability Family member prosecuted for criminal activity Family member attempted/committed suicide Physical abuse in your family Sexual abuse in your family Is there any other information about your mental health/emotional wellness that you believe will be pertinent to or could impact your care and treatment? Please explain below. I hereby certify that all the above information is true and correct to the best of my knowledge and belief. Signature Name Date
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
A New Tomorrow Behavioral Health Services
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C O U P L E S I N T A K E F O R M
COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
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Client Information Form
Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both
Life, Family and Relationship Questionnaire
Date of Initial Session: Client Name Date of Birth Address City Zip Phone Number Email Emergency Contact Relationship Emergency Contact Ph. # Client Name: Date: Life, Family and Relationship Questionnaire
Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
Personal Disclosure Statement and Notice of Practices
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Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
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Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
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Journey to Truth Counseling
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Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
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Amanda G. Johnson, LPC
Adult Personal Information Name Date Address Apt City State Zip Code E-mail Is it OK to contact you at this email address? YES NO Home Phone Is it OK to leave a message for you at this number? YES NO Cell
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
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CERTIFICATION AND AUTHORIZATION (if applicable)
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Health and Social Information 1. How is your physical health at present? (Please circle) Poor Unsatisfactory Satisfactory Good Very good
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Demographic Information Form
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Patient Registration Form
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Dear Applicant: Complete ONLY the individual sections where there is a current or recent concern.
Dear Applicant: Thank you for your interest in becoming a patient at the Children s Psychiatric Services of South Texas (CPSOST). In order to provide you with the best care, it is important for our medical
PATIENT INFORMATION & DISCLOSURE STATEMENT
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LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited
SAMPLE. Date of Birth: Age: Gender: Woman: Man: Transgender: Transman: Transwoman: Gender Nonconforming: Other:
Patient Intake Questionnaire Note: This is a sample intake questionnaire which includes a wide variety of potential questions that can be asked of new clients during the intake process. Providers are encouraged
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Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
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