This questionnaire will help me get to know a little more about your situation and how I may be of help to you. If you feel uncomfortable with any question you may leave it blank and we can discuss it when we meet.
ADOLESCENTS (please answer the following with Y/N)
How often do you see each parent?
Mom blanks %. Dad blank %
Please note that the information is important for your child’s care. Please fill out forms as completely as possible and have them ready before your first counseling session.
(If additional space is needed, please send a follow-up email)
If Yes, answer the following questions:
(Please answer the following as best as you can, we understand that you may not be able to answer some of the questions pertaining to the other parent
If divorced, how much time does your child spend with each parent?
This document contains important information about my professional services and business policies, including limits of confidentiality. Please read it carefully. When you sign this document, it will represent an agreement between us.
Cognitive Behavioral Therapy (CBT) is a form of therapy that is active, collaborative, goal-oriented, and is based on the cognitive model. That means we will work together to understand the role that our thoughts, beliefs, emotions, and behaviors play in our current struggles. In addition to support and insight, CBT offers client specific strategies, skills and tools that can be used to make changes, relieve suffering, and achieve goals. The focuses are primarily on individual adults and adolescents, ages ten and older.
Risks and Benefits of Therapy
Participating in therapy may result in a few benefits to you, including a deeper understanding of yourself and your personal goals in addition to improving your relationships with others. This will help motivate you in the beginning stages of therapy. However, the risks of therapy and benefits are the primary goal of therapy which may be to improve your well-being. It can also result in considerable discomfort; you may experience uncomfortable feelings such as sadness, guilt, anger, shame, frustration, loneliness, and helplessness. If you should have any concerns regarding your progress in therapy, it is important to let me know.
Records and Record Keeping
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead.
The information disclosed by you in therapy is confidential and will not be released to others without your written consent. However, there are a few exceptions.
Exceptions to confidentiality include: - If there is reason to believe a child, elderly person, or dependent adult is or has been abused!- If you threaten to commit serious bodily harm to yourself or another person!- If I am presented with a subpoena or court order that has been signed by a judge!In the above circumstances, I will only reveal the minimum information that is necessary, and I will inform you of the information being disclosed and to whom it will be provided before I do so.
Minors and Confidentiality
If you are a minor, under the age of 18, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents regarding what information is appropriate for them to receive and which issues are more appropriately kept confidential.
A standard session is 45-minutes, and the standard fee is $70.00. Sessions longer than 45-minutes are charged for the additional time. If I need to adjust my fees in the future, you will be notified of any fee adjustment in advance. Sliding scale fees are available on a limited basis. All fees are due at the time of service. If for some reason you find that you are unable to continue paying for your therapy, please let me know. I would be happy to help you to consider any options that may be available to you at that time.
Cancellation Policy My policy includes a 24-hour cancellation.If you do not show up for your scheduled therapy appointment and have not notified me at least 24- hours in advance, payment will be required for the full cost of the session. A total of two missed appointments without prior notification may lead to ending the therapy relationship.
Therapist Availability and Emergencies I will make every effort to return calls within 24 hours (or by the next business day) but cannot guarantee your call will be returned immediately. I am unable to provide 24-hour crisis service. If you are feeling unsafe or require immediate medical assistance, please call 911 or the 24-Hour Crisis Line at 1-800-715-4225 or go to the nearest local emergency room.
Termination of Therapy Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Therefore, I may terminate treatment after appropriate discussion with you, if I determine that the sessions are not being effectively used or if you are in default on payment, I will not terminate the therapy relationship without first discussing and exploring the reasons and purpose of terminating. You also have the right to terminate therapy at your discretion.
CONSENT TO TREATMENT
I,blanks , have read Agreement for Services/Informed Consent. In signing below, I consent to treatment and agree to abide by in terms during therapy.