Emily Keller, PhD, LPC, RPT 659 Edwards Ridge Road Chapel Hill, NC, 27512 (919) 929 1171; ekeller@seinstitute.com Licensed Professional Counselor & Registered Play Therapist INTAKE INFORMATION Client Name: Date: Gender: Date of birth: Age: Address: City: State: Zip: Preferred phone: Email address: Referred by: What are your goals for therapy? Do you feel suicidal at this time? Yes No, If Yes, explain: Have you ever attempted suicide? Yes No, If Yes, when? Describe: Have you experienced major changes/events during the past year? Yes No If yes, describe: Are you seeing anyone else for psychological care? Yes No, If Yes, who and what are your therapeutic goals? List prescription medications: Have you had previous counseling or psychotherapy? Yes No, If yes, describe the experience: 1 Page
Emily Keller, PhD, LPC, RPT 659 Edwards Ridge Road Chapel Hill, NC, 27512 (919) 929 1171; ekeller@seinstitute.com Licensed Professional Counselor & Registered Play Therapist Behaviors/symptoms Indicate the behaviors/symptoms that occur more often than you would like: Anger/aggression Alcohol/drug use Antisocial behavior Anxiety Avoidance Chest pain Critical of self/other Cyber/internet use Depression Disorientation Distractibility Dizziness Elevated mood Fatigue Gambling Hallucinations Heart palpitations Heart palpitations Hopelessness Impulsivity Irritability Loneliness Memory impairment Mood shifts Over /under eating Panic attacks Phobias/fears Recurring thoughts Sexual difficulties Sexual thoughts/acts Sleep problems Suicidal thoughts Thoughts disorganized Trembling Withdrawing Worrying Yelling Other: General Life Balance Not Balanced 1 2 3 4 5 6 7 8 9 10 Fully Balanced Education/Career Highest degree: Degree in: Occupation: Other: Military experience? Yes No, Describe: Your Family Describe Your Marital Status: Your Children: List names, ages, and other pertinent information: 2 Page
Emily Keller, PhD, LPC, RPT 659 Edwards Ridge Road Chapel Hill, NC, 27512 (919) 929 1171; ekeller@seinstitute.com Licensed Professional Counselor & Registered Play Therapist Family of Origin Parents: Married/Together Divorced/Separated Mother remarried; Number of times: Father remarried; Number of times: Special circumstances (e.g., raised by person other than parents) Development Are there unusual or traumatic circumstances that affected your development? Yes No If Yes, describe: Is there a history of abuse? Yes No If Yes, which type(s)? Sexual Physical Verbal If Yes, the abuse was as a: Victim Perpetrator Other childhood issues: Neglect Inadequate nutrition Other (please specify): Cultural/Ethnic To which cultural or ethnic group do you belong? Are you experiencing any problems due to cultural or ethnic issues? Yes No If Yes, describe: Other cultural/ethnic information: Religious/Spiritual How important to you is religion/spirituality? Not at all important A little important Moderately important Very important Do you belong to a religious or spiritual group? Yes No Which? Do your religious or spiritual beliefs help you cope in life? Explain: Would you like your spiritual/religious beliefs incorporated into the counseling? Yes No 3 Page
Emily Keller, PhD, LPC, RPT 659 Edwards Ridge Road Chapel Hill, NC, 27512 (919) 929 1171; ekeller@seinstitute.com Licensed Professional Counselor & Registered Play Therapist If Yes, describe: Support Network My network of support and encouragement includes the following: Recent changes to my support network include: Medical/Physical Health Describe past/current medical issues: Have you ever been hospitalized? Describe. _ Substance Abuse Questions Describe past/current issues with alcohol/drugs: List 3 things for which you are grateful: What do you like about yourself? _ Other What else would you like me to know, that is relevant to your treatment? _ 4 Page
Emily Keller, PhD, LPC, RPT 659 Edwards Ridge Road Chapel Hill, NC, 27512 (919) 929 1171; ekeller@seinstitute.com Licensed Professional Counselor & Registered Play Therapist COUNSELING AGREEMENT READ AND SIGN THE FOLLOWING PRIOR TO SEEING EMILY KELLER, PHD, LPC, RPT. Before we begin a journey of working together, it is important to me that you understand the nature of the therapeutic relationship and the nature of the change you want to make. The clearer you are about how you want to change, the more focused our work will be. In fact, your therapeutic goal becomes our therapeutic contract and we will refer to the contract throughout the process. Eric Berne defined a contract as an explicit bilateral commitment to a well defined course of action. The goal of our first meeting is to determine if I am a good match in helping you along your particular well defined course of action. To meet that goal, you will share how you want to change and I will orient you to psychotherapy in general (risks, benefits, confidentiality, limits of confidentiality, etc.), and my theories of choice, specifically transactional analysis. I will also share with you information about privacy, how I maintain records, and your rights as a client. Part of my goal is to demystify the therapeutic process. Some of the above will be covered in this document. Prior to establishing a therapeutic contract for change, we will establish a working contract. The working contract is also described in this document and includes information about office hours, meeting places, fees, termination, etc. As you read this document, note any questions you have. We will review them at our first meeting. Therapy is a big investment. You will be committing time, money, and energy to this process. It is important that you carefully select a therapist. Then, give the therapeutic process a chance by not only showing up during our scheduled sessions, but also by completing reading assignments, questionnaires, and other exercises on your own. HOW I WORK I am a Licensed Professional Counselor in the state of Texas (#66876) and Licensed Professional Counselor in the state of North Carolina (#11488). I am also a Registered Play Therapist specializing in parent child attachment. I generally meet with clients in my office for 60 minute sessions. I meet with children for 30 minutes. I use Therasoft.com for record management and for HIPAA compliant video conferencing and messaging. I do this because I want clients to have options for meeting with me. I do not guarantee a time frame for our work. I will keep us on track by referring back to your original contract for change, though, the original therapeutic contract does generally evolve as the therapy evolves, and sometimes due to outside circumstances (for example, a sudden shift to focus on grief and loss due to a recent death).
In addition to Masters and doctoral level graduate work, I completed a post graduate program at the Southeast Institute for Group and Family Therapy and a training program through the Couples Institute. I generally attend at least three conferences a year as well as a number of workshops to receive continuing education. I serve TA organizations at the national and international level. As your counselor, I will do my best to apply my education and experience to help you reach your therapeutic goals. Additionally, I uphold standards of ethics outlined by the American Counseling Association (ACA). Professionally and ethically, my relationship with you is strictly professional. This is not personal. It is a boundary that is central to successful outcomes. This means I don t barter for services, I don t do business with clients, and I don t socialize in person or online. In fact, if I see you in public I won t approach you, as that alone could be a breach of confidentiality. CONFIDENTIALITY Confidentiality means that I have a responsibility to safeguard information obtained during counseling. All identifying information about your assessment and treatment is kept confidential, except as mandated by law. You must sign a release of information before any information about you is given to anyone, except as mandated by law. In certain situations, mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your consent. In such situations, your counselor is not required to inform you of her actions. Please note the following exceptions to confidentiality: Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly. Confidentiality does not apply to cases of potential harm to self or others. A mental health professional may disclose confidential information in proceedings brought by a client against a professional. Confidentiality does not apply to cases involving criminal proceedings, except communications by a person voluntarily involved in a substance abuse program. Confidentiality may not apply in cases involving legal proceedings affecting the parent child relationship. Confidentiality may not apply to cases involving a minor child. In such cases, the mental health professional may advise a parent, managing conservator or guardian of a minor, with or without minor s consent, of the treatment needed by or given to the minor. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) I am required by law to protect the privacy of your health information. Although your records are the physical property of Emily Keller, PhD, LPC, RPT, the information contained in your health record belongs to you. You have the right to: request a restriction on certain uses and disclosures of your information inspect and obtain a copy of your health record 2
amend your health record as provided by regulation obtain an accounting of disclosures of your health information as provided by law request communications of your health care information by alternative means or locations revoke your authorization to use or disclose health information except to the extent that action has already been taken. I will supply you with a paper copy of the full Notice of Privacy Policy at our first meeting. THE BENEFITS OF COUNSELING One major benefit of counseling is the resolution of the concerns brought to therapy. Other benefits may include a better ability to cope with marital, family and other interpersonal relationships, and /or a greater understanding of personal goals and values. In fact, clients can grow in many unexpected ways. THE RISKS OF COUNSELING There are certain risks involved in counseling. You may experience a variety of negative emotions during therapy as you remember and therapeutically resolve unpleasant events. Seeking to resolve concerns between family members, marital partners, and other persons can similarly lead to discomfort as well as relationship changes that may not be originally intended. The greatest risk of counseling is that it may not by itself resolve your concerns. Your counselor will do his or her best to assess progress and provide referral to other sources if that is deemed necessary and appropriate. Psychotherapy is a collaborative process and the progress you make will depend in large measure upon your investment in the process. If you feel that you need emergency attention, go to the nearest emergency room, or call 911. COST OF SERVICE PAYMENT In person (60 minutes/$150) Secure video or phone session from your location (30 minutes/$75; 60 minutes/$150) Group Therapy (90 minute sessions/$65) All fees will be paid at the time the service is rendered. Cash, check and credit card are welcome. You will be billed to obtain fees in the case of no payment, not showing up to an appointment, or cancelling within the 24 hour timeframe. CANCELLATIONS Three consecutive cancellations of appointments will result in termination of service, which will be communicated by mailed correspondence. Last minute cancellation of the first appointment will require 3
payment in advance to schedule another first appointment. Cancellations must be made 24 hours in advance to avoid being charged 100% of the fee. Missed appointments will be charged 100% of the fee. TERMINATION OF THERAPEUTIC RELATIONSHIP Upon reaching your therapeutic goals, non communication, three consecutively missed appointments, general agreement, or for other reasons that indicate that we are not working together consistently or do not need to continue working together, I will mail you a termination letter. In this letter, I will note that we may resume our therapeutic relationship at another time and/or I will offer you referral sources to continue treatment with someone else. I will mail this letter to you at the address you provide at the end of this form. VACATION, WEEKENDS, AND TIME AWAY I will sometimes take vacation or be absent due to training, family emergencies, etc. If, during my absence, or in case you can t get ahold of me for any other reason such as it is a weekend, evening hours, or she is in session, and you experience an emergency, proceed to the nearest emergency room or call 911. I am not always available to answer calls or emails during evening hours or on weekends, or during work hours and while in session. I will do my best to return calls within 48 hrs. DUAL RELATIONSHIPS This is a therapeutic relationship. Counselors do not engage in dual relationships with clients. This includes business relationships and social relationships in person or online. This general guideline is in accordance with confidentiality standards and helps avoid unwanted social introductions and/or breaches of privacy. SOCIAL NETWORKING I will not solicit or accept friendship or other requests via Facebook, Linked In, Pinterest, or other similar social media platforms. I take this measure to safeguard your confidentiality. If you Like my Facebook page, please know others might assume that you are a client. COMMUNICATIONS AND PRIVACY While I do my best to keep your information private, I cannot guarantee the security of emails, text messages, and voice communications. Many clients choose to use these electronic methods to communicate with me. While they are convenient forms of communication, they are not error proof. Please know that technology failures could prevent messages from being delivered; That I don t check messages throughout the day, and sometimes not at all on days that I am not working and on vacation; That messages may not be secure in transmission; That text messages are easily viewed by other people; There are multiple points of potential breaches of electronic information transmission; My email is not encrypted. 4
I suggest that clients limit text messages to information about appointment dates and times. I assume that if you text or email me, then I can text or email you back at that same number/address. CONTACT INFORMATION Emily Keller, PhD, LPC, RPT, may contact me by USPS mail service, may email me, and may leave a voicemail message at the following points of contact (if I leave it blank, she may not): Email: Address: Phone: Check One: It is OK for Emily Keller, PhD, LPC, RPT, to text me. It is NOT OK for Emily Keller, PhD, LPC, RPT, to text me. (Initial) I understand that return address information will be on all mailed correspondence. (Initial) I understand that cell phone text messaging and emails are not secure forms of communication. WRITTEN ACKNOWLEDGEMENT AND CONSENT TO COUNSELING I have read and accept this agreement and herewith consent to counseling/psychotherapy treatment. Client Signature Date Parent/Guardian Signature (if client is a minor) Date Emily R. Keller, PhD, LPC, RPT Date 5
659 Edwards Ridge Road Chapel Hill, NC, 27517 919) 929-1171 registrar@seinstitute.com SEI Payment Policy Credit Card and Debit Card Agreement Southeast Institute policy is payment is required on the day of service or before. Payment may be made by check, cash or credit card. Please note that you are responsible for all charges incurred for your treatment or the treatment of those for whom you are responsible. At Southeast Institute, we require keeping your credit or debit card on file as a convenient method of payment. If an outstanding balance" is owed then we will charge your credit card on file. I authorize Southeast Institute to charge the portion of my bill that is my financial responsibility to the following credit or debit card: Amex Visa MasterCard Discover Credit Card Number Expiration Date / / CVV Number (3 digit code) Cardholder Name Signature Billing Address City State Zip I (we), authorize and request Southeast Institute to charge my credit card, indicated above, for balances due for services rendered financial responsibility. This authorization relates to all payments provided to me by Southeast Institute. This authorization will remain in effect until I (we) cancel this authorization. To cancel, I (we) must give a 60 day notification to Southeast Institute in writing and the account must be in good standing. Patient Name (Print): Patient Signature: Parent/Guardian Signature (if client is child/teen): Date: / / Southeast Institute 659 Edwards Ridge Rd Chapel Hill, NC 27517 Office (919) 929-1171 Fax (919) 929-1174 Email registrar@seinstitute.com Website www.seinstitute.com