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Intake Form for Schools and Organizations
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15
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1
Name of your School or Organization
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2
Physical Address of your School or Organization
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Website Address of your School or Organization
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4
Contact Person's Name
First Name
Last Name
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5
Contact Person's Email Address
example@example.com
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6
Contact Person's Phone Number
Area Code
Phone Number
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7
Please describe the reason you are seeking services
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8
Is this an organization or school-wide issue?
YES
NO
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9
If not, which area/grade/division is impacted?
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10
How did you hear about Shine Bright Counseling?
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11
Consent to Treatment and Confidentiality
*
This field is required.
We are committed to providing you with quality care. Please take a few minutes to read the following information that will explain confidentiality and policies and procedures to you. If you have any questions, please ask and we will be happy to clarify any of the information in this form. Please sign and date this form acknowledging that you have read and fully understood the confidentiality and privacy information and are consenting to begin services. Thank you. Consent to Treatment: I, voluntarily, agree to receive or authorize an assessment, treatment or service and care and authorize Shine Bright Counseling and Counseling to provide such care, treatment or service as are considered necessary and advisable. I understand and agree that I will participate in the planning of the care, treatment or service and that I may stop such care, treatment or services that are provided but Shine Bright Counseling and Consulting. Emergencies:
You may encounter a personal emergency that may require prompt attention. Your clinician will make reasonable efforts to respond to your emergency in a timely manner. If it is after-hours or on a weekend, or you reach the office voicemail during an emergency situation, please go to the nearest emergency room, and ask for assistance regarding a mental health emergency or call 911. Appointments:
Services are by appointment only. You are responsible for keeping your appointment and timely arrival. In the event that you cannot keep an appointment, it is your responsibility to call/text your clinician at least 24 hours in advance to cancel or reschedule. No-shows or cancellations within 24 hours will be charged the regular session rate. Any type of audio/visual recording is prohibited in sessions, without prior discussion and consent. Confidentiality:
You are protected by the confidentiality laws in Texas, which state that anything discussed during sessions and meetings is privileged information and cannot be shared with anyone else without your consent. This also means that we cannot tell anyone whether you are receiving services from Shine Bright Counseling and Consulting, PLLC without your permission.
Possible exceptions to confidentiality include those provided by laws, including but not limited to child abuse, abuse, neglect, or exploitation of the elderly or the disabled; AIDS/HIV infection and possible transmission; criminal prosecution; child custody cases. These records are confidential pursuant to certain legal and ethical limits and clinical parameters, and the HIPAA Notice of Privacy Practices. Within these limits, the information revealed by you will be kept confidential. No information will be released without your written consent and authorization unless mandated by law. Possible legal exceptions to confidentiality include, but are not limited to, the following situations: · If you reveal information that indicates, you are a danger to yourself or someone else necessitating a duty to protect or duty to warn. · If you reveal information about child abuse, neglect, elder abuse or sexual exploitation. · If you are in therapy as the result of a court order, unless otherwise stated in the court order. · If I receive a subpoena or a court order to disclose information. · If you provide written permission or direction to release your record. If you have any questions or concerns regarding confidentiality, please discuss them with your Shine Bright counselor before signing this form. Consent to Treatment and Confidentiality
:
By signing this Client Information and Consent Form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing, and I understand that I may stop such treatment or services, not under court order, at any time.
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12
Telemental Health Informed Consent
*
This field is required.
I consent to Telemental Health, if we mutually determine that it is an appropriate means to communicate. I understand that Telemental Health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are in different physical locations. Shine Bright Counseling and Consisting, PLLC utilizes Doxy.Me. This internet platform is encrypted to the federal standard, PIPAA compatible and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Doxy. Me is willing to attest to HIPAA compliance and assumes responsibility for keeping the live video interaction secure and confidential. If you choose to utilize this technology, Shine Bright PLLC will give you detailed directions regarded how to log-in securely. Shine Bright Counseling and Consulting, PLLC requests that you sign onto the platform at least 5 minutes prior to your session time to ensure a prompt start time and strongly suggests that you online communicate through a computer or device that you know is safe. I understand the following with respect to Telemental Health: 1) I understand that I have the right to withdraw consent at any time without affecting my right to further care, services or program benefits to which I would otherwise be entitled. 2) I understand that there are risks and consequences associate with Telemental Health, including but not limited to, disruption of transmission by technology failures, interruption and/or breach of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. 3) I understand that there will be not recording of any of the online session by either party. All information disclosed with sessions and written record pertaining to those session is confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law. 4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to Telemental Health unless a legal exception to confidentiality applies. 5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experience a mental health crisis that cannot be resolved remotely, it may be determined that Telemental Health service are not appropriate and a higher level of care is required. 6) I understand that during a Telemental Health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect with in ten minutes, the session will be rescheduled. 7) I understand that my counselor may need to contact to an emergency contact and or appropriate authorities in case if emergencies. I acknowledge receipt of this Telemental Health notice and agree to its terms. If yes, please submit your electronic signature below.
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13
I would like paper copies of the previously signed consent forms.
If yes, please indicate which forms.
Consent to Treatment and Confidentiality
Telemental Health Informed Consent
I do not need paper copies
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14
Complaint Process
If you believe that Shine Bright Counseling & Consulting, PLLC has violated your privacy rights, you have the right to file a complaint. You may complain by contacting: You may also file a complaint with: U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 (800) 368-1019 (toll free) You must file your complaint within 180 days of when you knew or should have known about the event that you think violated your privacy rights. You will not be retaliated against if you file a complaint.
Effective Date: April 14, 2020 I acknowledge receipt of this privacy notice
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NO
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