Uniquely Centered Therapeutic ServiceClient Intake Application

Uniquely Centered Therapeutic ServiceClient Intake Application
Welcome to Uniquely Centered Therapeutic Service (UCTS). We are so glad you are here. Taking this step is a powerful investment in your relief, growth, and resilience. This intake form helps us understand your unique story, protect your privacy under federal HIPAA regulations, and prepare for our very first session together. Please take your time filling this out. We look forward to walking alongside you!
Section 1: Care Preference
How would you like us to meet?
Today's date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name (Please enter your legal name as it appears on your ID or insurance):

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Biological Sex (Required for insurance purposes)
Gender Identity (How you navigate and identify in the world)
Heritage: Ethnicity/Cultural Background
Social Security Number:

Section 2: Address & Secure Contact Preferences
Home Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Primary Mobile Phone
Format: (000) 000-0000.
May we leave a voicemail message or text at this number
Secondary Phone number (if applicable)
Format: (000) 000-0000.
May we leave a voicemail message or text at this number
Email Address: We use this for scheduling updates, secure portal links, and digital resources.
example@example.com
Emergency Contact
Who should we contact in the rare event of a medical or safety emergency during our care?
Contact Name

First NameLast Name
Relationship to client
Phone Number
Format: (000) 000-0000.

Section 4: Medical History, Safety Tracking, & Background
Medical Conditions
Please list any current medical conditions or major physical health concerns you are managing.
Type NA if not applicable.
Medications
Please list any prescriptions, over-the-counter medications, or active supplements you are currently taking, along with dosages if known.
Type NA if not applicable.
Medical Providers
Please provide the name and contact info of your current primary care physician (PCP) and psychiatrist.

Section 5: Safety and Crisis Tracking
At Uniquely Centered, your absolute safety is our top priority. The following standard questions help us understand if you need immediate crisis protection, specialized safety planning, or extra stabilization resources alongside your standard therapy. Please answer as honestly as possible so we can support you fully.
Self-Harm Tracking
Are you currently engaging in any self-harming behaviors?
Have you attempted to kill yourself?
Have you ever physically attacked or been in a physical altercation with someone else?
If you answered "Yes" to either question above, or if you have a past history of suicide attempts or severe safety crises, please share briefly so we can prioritize your care.

Section 9: Protecting Out Time Together (Cancellation Policy)
To ensure all of our clients get the consistent care they deserve, your therapist reserves a specific hour just for you. If you need to cancel or reschedule your appointment, please provide at least 24 hours' notice.
I have read and understand the scheduling and cancellation policy.

Section 10: Credentials, Professional Organizations, and Ethics
In our professional work, we are firm and enthusiastic believers in professional organizations and codes of ethics as methods by which we hold ourselves accountable and by which you, as our client, can hold us accountable. They offer guidance in difficult situations. It is important for you to know our credentials so that you know what standard of care we should be providing you, as well as who to contact should you feel your therapist is doing something unethical. We are licensed by the State of Ohio. As with all professional counselors in Ohio, we work under clinical supervision and direction. This ensures that we are providing you with the highest quality of care possible, and it provides you with an objective professional to contact, should you ever need to, regarding the care we have provided.

Current Clinical Supervisor: LaDrina Eves LPCC

Supervisors Contact Info: ladrina@uniquelycenteredservice.com/513-671-8287 Ext. 1

Licensing Board: State of Ohio Counselor, Social Worker, and Marriage and Family Therapist Board (CSWMFT Board)
I have read and understand the therapist's credentials, ethical guidelines, and supervisory structure.

Section 11: Risk and Benefits of the Counseling Process
Counseling can involve difficult discussions, emotional discomfort, and challenges to your beliefs, with no absolute guarantee of success or linear progress. Lasting change requires time, commitment, and adherence to the full therapeutic process from consultation through termination, rather than stopping prematurely after initial relief. You may also be given voluntary out-of-session "homework" tailored to your willingness and ability.
I have read and understand the risk and benefits of the counseling process.

Section 12: Privacy & Limits to confidentiality
We will do whatever is legally and ethically appropriate and allowable, to the best of our skills and abilities, to keep your personal information private. What you say in our sessions together is covered by legal confidentiality, so long as it falls within the legal limitations.

Those limitations are as follows for Uniquely Centered Therapeutic Service, LLC:

Safety & Protection: If your therapist has a concern that you are in any way in danger of hurting yourself or others, we are required by law to contact the appropriate authorities.
Abuse Reporting: If your therapist has a concern that a child or an elder is being abused by anyone (not necessarily yourself) as of the result of the conversations in session, we are required to report it to the appropriate authorities.
Legal Subpoenas: If we are subpoenaed by a court of law to present information regarding your care, or to testify regarding your care, we may be required to do so depending on the situation.

Our Commitment to you is that any situations where confidentiality must be broken, your therapist is committed to informing you as much as is ethically required and appropriate. Your therapist, in any of these situations, will consult with his/her supervisor, his/her director, and other professionals prior to taking any action. Furthermore, your therapist will limit any such release to only what is required by law and our code of ethics. In all other circumstances such as coordinating care with another counselor, psychologist, doctor, or psychiatrist, your therapist requires that you sign an official Release of Information (ROI) authorization before we discuss your treatment with anyone.
I have read, understand, and agree to the limits of confidentiality outlined above.

Section 13: Record Keeping & Documentation
Your therapist will be keeping records of your sessions such as names of people that you mention, details of experiences which we think are therapeutically important, goals we discuss, or impressions that we have.

Why We Keep Records:
These notes are kept so that we do not forget important details, so that we can ensure a direction with your care, and to ensure continuity of care should anything happen to your therapist. These records will not be shared with anyone except with respect to the limits of confidentiality detailed above.

Accessing Your Records:
Should you wish to have copies of your records or have them released, we will require a signed release form. We will release whatever is ethically appropriate and maintain your privacy to the best of our ability.

Security & Storage Methods:
Our records at Uniquely Centered Therapeutic Service, LLC are kept both electronically and manually (on paper):
- Our online practice management system is entirely HIPAA-compliant and secure.
- Any physical paper files are kept safely in a locked filing cabinet.
- Clinical records are kept for an indefinite amount of time.
I have read and understand how my clinical records are documented, stored, and accessed.

Section 14: Therapist Inability to Render Care & Continuity of Care
Your long-term well-being and stability are very important to us. To ensure you are always supported, Uniquely Centered Therapeutic Service, LLC maintains clear backup plans for both scheduled vacations and unexpected emergencies.

Emergency Backup (Inability to Render Care):
Should an unexpected event occur where your therapist is suddenly unable to provide you with
care (such as a severe accident, illness, or death), you will be contacted directly by one of our trusted partners here at Uniquely Centered. To ensure the continuity of your healing process, this partner will be granted secure access to your clinical records—only as strictly necessary—to help seamlessly transition or coordinate your ongoing care.

Vacation & Planned Absences:
When your therapist takes a planned vacation or extended leave, your care does not have to pause. Upon your request, we are happy to connect you with one of our practice partners who can provide temporary coverage and support while your therapist is away.
I have read and understand the practice policies regarding vacation coverage and emergency continuity of care.

Section 15: Contacting Your Therapist & Managing Appointments
Clear communication keeps our partnership with you strong. To ensure you can easily manage your scheduling needs, your assigned therapist will provide their direct contact to you at the conclusion of your very first session. Please use the contact option for your therapist whenever you need to reschedule, cancel, or adjust an upcoming session.

Note: For immediate clinical crises or life-threatening emergencies prior to establishing this contact, please call 911 or go to your nearest emergency room.
I understand how and when I will receive my therapist's direct contact information for scheduling changes.

Section 16: Session Expectations & Mutual Respect
To get the absolute most out of our time together, we ask that you arrive focused and ready to engage.

Punctuality Policy:

It is our practice policy that when attending sessions, you please be prompt and on time. We extend a 10-minute courtesy window for individuals who have proactively notified their therapist that they are running late. Arriving past this window without notification may result in a shortened or canceled session.

Couples & Family Sessions Expectations:

For family and couples counseling, the expectation is that all parties involved remain respectful to one another and actively participate throughout the entire session. Creating a safe space requires mutual effort from everyone in the room.
I understand and agree to follow the punctuality and respect guidelines for my sessions.

Section 17: Termination of Care & Ongoing Support
Reaching the end of your counseling journey is a significant milestone. At Uniquely Centered Therapeutic Service, LLC, we view termination as a collaborative, intentional process designed to honor your progress and ensure you feel stable moving forward.

Our Planned Transition Process:

We will move toward termination at whatever pace is comfortable and therapeutically beneficial for you.

Your Right to Choose:

You are entirely within your rights to terminate your care at any time. All clinical records remain strictly confidential even after care ends.
Sudden Discontinuations & Safety:
If you choose to stop counseling suddenly, your therapist will do their due diligence to ensure your well-being. We will follow up via phone, email, or a formal closing letter to confirm your wishes and officially close your active file.

Formal Closure:
In all cases of termination, please expect an email from your therapist formally closing your care and requesting your valuable feedback via a brief online survey to help us improve our services.
I understand and agree to the collaborative transition and termination policies outlined above.

Section 18: Health Insurance Portability and Accountability Act (HIPPA)
I. Commitment to Your Privacy
Uniquely Centered Therapeutic Service, LLC is dedicated to maintaining the privacy of your protected health information (PHI). PHI is information that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. This Notice of Privacy Practices is required by law to provide you with the legal duties and the privacy practices that Uniquely Centered Therapeutic Service, LLC maintains concerning your PHI. It also describes how medical and mental health information may be used and disclosed, as well as your rights regarding your PHI. Please read carefully and discuss any questions or concerns with your therapist.
II. Legal Duty to Safeguard Your PHI
By federal and state law, Uniquely Centered Therapeutic Service, LLC is required to ensure that your PHI is kept private. This Notice explains when, why, and how Uniquely Centered Therapeutic Service, LLC would use and/or disclose your PHI.
- Use of PHI means when Uniquely Centered Therapeutic Service, LLC shares, applies, utilizes, examines, or analyzes information within its practice.
- Disclosure of PHI means when Uniquely Centered Therapeutic Service, LLC releases, transfers, gives, or otherwise reveals it to a third party outside of the practice.
With some exceptions, Uniquely Centered Therapeutic Service, LLC may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, Uniquely Centered Therapeutic Service, LLC is always legally required to follow the privacy practices described in this Notice.
III. Changes to This Notice
The terms of this notice apply to all records containing your PHI that are created or retained by Uniquely Centered Therapeutic Service, LLC. Please note that Uniquely Centered Therapeutic Service, LLC reserves the right to revise or amend this Notice of Privacy Practices. Any revision or amendment will be effective for all of your records that Uniquely Centered Therapeutic Service, LLC has created or maintained in the past and for any of your records that Uniquely Centered Therapeutic Service, LLC may create or maintain in the future. Uniquely Centered Therapeutic Service, LLC will have a copy of the current Notice in the office in a visible location at all times, and you may request a copy of the most current Notice at any time. The date of the latest revision will always be listed at the end of Uniquely Centered Therapeutic Service, LLC's Notice of Privacy Practices.
IV. How Uniquely Centered Therapeutic Service, LLC May Use and Disclose Your PHI
Uniquely Centered Therapeutic Service, LLC will not use or disclose your PHI without your written authorization, except as described in this Notice or as described in the "Information, Authorization and Consent to Treatment" document. Below you will find the different categories of possible uses and disclosures:
1. For Treatment: Uniquely Centered Therapeutic Service, LLC may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If you are also seeing a psychiatrist for medication management, Uniquely Centered Therapeutic Service, LLC may disclose your PHI to her/him to coordinate your care. Except for in an emergency, Uniquely Centered Therapeutic Service, LLC will always ask for your authorization in writing prior to any such consultation.
1. For Health Care Operations: Uniquely Centered Therapeutic Service, LLC may disclose your PHI to facilitate the efficient and correct operation of its practice. Example: Quality control: Uniquely Centered Therapeutic Service, LLC may provide your PHI to its office personnel, accountants, practice consultants, attorneys and others to make sure that Uniquely Centered Therapeutic Service, LLC is in compliance with applicable practices and laws. It is Uniquely Centered Therapeutic Service, LLC's practice to conceal all client names in such an event and maintain confidentiality. However, there is still a possibility that your PHI may be audited for such purposes.
1. To Obtain Payment for Treatment: Uniquely Centered Therapeutic Service, LLC may use and disclose your PHI to bill and collect payment for the treatment and services Uniquely Centered Therapeutic Service, LLC provided you. Example: Uniquely Centered Therapeutic Service, LLC might send your PHI to your insurance company or managed health care plan, in order to get payment for the health care services that have been provided to you. Uniquely Centered Therapeutic Service, LLC could also provide your PHI to billing companies, claims processing companies, and others that process health care claims for Uniquely Centered Therapeutic Service, LLC's office if either you or your insurance carrier is not able to stay current with your account. In this latter instance, Uniquely Centered Therapeutic Service, LLC will always do its best to reconcile this with you first prior to involving any outside agency.
1. Employees and Business Associates: There may be instances where services are provided to Uniquely Centered Therapeutic Service, LLC by an employee or through contracts with third-party "business associates." Whenever an employee or business arrangement involves the use or disclosure of your PHI, Uniquely Centered Therapeutic Service, LLC will have a written contract that requires the employee or business associate to maintain the same high standards of safeguarding your privacy that is required of Uniquely Centered Therapeutic Service, LLC.
  Note: Ohio and Federal law provides additional protection for certain types of health information, including alcohol or drug abuse, mental health and AIDS/HIV, and may limit whether and how Uniquely Centered Therapeutic Service, LLC may disclose information about you to others.
V. Use and Disclosure of Your PHI in Certain Special Circumstances
Uniquely Centered Therapeutic Service, LLC may use and/or disclose your PHI without your consent or authorization for the following reasons:
1. Law Enforcement: Subject to certain conditions, Uniquely Centered Therapeutic Service, LLC may disclose your PHI when required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement. Example: Uniquely Centered Therapeutic Service, LLC may make a disclosure to the appropriate officials when a law requires Uniquely Centered Therapeutic Service, LLC to report information to government agencies, law enforcement personnel, and/or in an administrative proceeding.
2. Lawsuits and Disputes: Uniquely Centered Therapeutic Service, LLC may disclose information about you to respond to a court or administrative order or a search warrant. Uniquely Centered Therapeutic Service, LLC may also disclose information if an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tecum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel. Uniquely Centered Therapeutic Service, LLC will only do this if efforts have been made to tell you about the request and you have been provided an opportunity to object or to obtain an appropriate court order protecting the information requested.
3. Public Health Risks: Uniquely Centered Therapeutic Service, LLC may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, disability, to report births and deaths, and to notify persons who may have been exposed to a disease or at risk for getting or spreading a disease or condition.
4. Food and Drug Administration (FDA): Uniquely Centered Therapeutic Service, LLC may disclose your PHI to the FDA relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.
5. Serious Threat to Health or Safety: Uniquely Centered Therapeutic Service, LLC may disclose your PHI if you are in such a mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine in good faith that disclosure is necessary to prevent the threatened danger. Under these circumstances, we may provide PHI to law enforcement personnel or other persons able to prevent or mitigate such a serious threat to the health or safety of a person or the public.
6. Minors: If you are a minor (under 18 years of age), Uniquely Centered Therapeutic Service, LLC may be compelled to release certain types of information to your parents or guardian in accordance with applicable law.
7. Abuse and Neglect: Uniquely Centered Therapeutic Service, LLC may disclose PHI if mandated by Ohio child, elder, or dependent adult abuse and neglect reporting laws.
Example: If we have a reasonable suspicion of child abuse or neglect, Uniquely Centered Therapeutic Service, LLC will report this to the appropriate local Ohio Public Children Services Agency (PCSA) or the Ohio Department of Job and Family Services (ODJFS).
8. Coroners, Medical Examiners, and Funeral Directors: Uniquely Centered Therapeutic Service, LLC may release PHI about you to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person, determine the cause of death, or perform other duties as authorized by law. We may also disclose PHI to funeral directors, consistent with applicable law, to carry out their duties.
9. Communications with Family, Friends, or Others: Uniquely Centered Therapeutic Service, LLC may release your PHI to the person you named in your Durable Power of Attorney (if you have one), to a friend or family member who is your personal representative (i.e., empowered under state or other law to make health-related decisions for you), or any other person you identify, relevant to that person's involvement in your care or payment related to your care. In addition, we may disclose your PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition.
10. Military and Veterans: If you are a member of the armed forces, Uniquely Centered Therapeutic Service, LLC may release PHI about you as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
11. National Security, Protective Services for the President, and Intelligence Activities: Uniquely Centered Therapeutic Service, LLC may release PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations for intelligence, counterintelligence, and other national activities authorized by law.
12. Correctional Institutions: If you are or become an inmate of a correctional institution, Uniquely Centered Therapeutic Service, LLC may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.
13. For Research Purposes: In certain limited circumstances, Uniquely Centered Therapeutic Service, LLC may use information you have provided for medical or psychological research, but only with your written authorization. The only circumstance where written authorization would not be required is if the information could be completely disguised in such a manner that you could not be identified, directly or through any identifiers linked to you. The research would also need to be approved by an institutional review board that has examined the research proposal and ascertained that the established protocols have been met to ensure the privacy of your information.
14. For Workers' Compensation Purposes: Uniquely Centered Therapeutic Service, LLC may provide PHI in order to comply with Workers' Compensation or similar programs established by law.
15. Appointment Reminders: Uniquely Centered Therapeutic Service, LLC is permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that you may need or that may be of interest to you.
16. Health Oversight Activities: Uniquely Centered Therapeutic Service, LLC may disclose health information to a health oversight agency for activities such as audits, investigations, inspections, or licensure of facilities. These activities are necessary for the government to monitor the health care system, government programs, and compliance with laws. Example: When compelled by the U.S. Secretary of Health and Human Services to investigate or assess Uniquely Centered Therapeutic Service, LLC's compliance with HIPAA regulations.
17. Required by Law: Uniquely Centered Therapeutic Service, LLC will disclose PHI when disclosure is otherwise specifically required by federal, state, or local law.
VI. Other Uses and Disclosures Require Your Prior Written Authorization
In any other situation not covered by this notice, Uniquely Centered Therapeutic Service, LLC will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying Uniquely Centered Therapeutic Service, LLC in writing of your decision. You understand that we are unable to take back any disclosures already made with your permission, we will continue to comply with laws that require certain disclosures, and we are required to retain records of the care that our therapists have provided to you.
VII. Rights You Have Regarding Your PHI
1. The Right to See and Get Copies of Your PHI: In general, you have the right to see your PHI that is in Uniquely Centered Therapeutic Service, LLC’s possession, or to get copies of it; however, you must request it in writing. If we do not have your PHI, but know who does, you will be advised how you can get it. You will receive a response from us within 30 days of receiving your written request. Under certain circumstances, we may feel we must deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have our denial reviewed. If you ask for copies of your PHI, you will be charged not more than $0.25 per page and the fees associated with supplies and postage. Uniquely Centered Therapeutic Service, LLC may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
2. The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask that Uniquely Centered Therapeutic Service, LLC limit how it uses and discloses your PHI. While we will consider your request, we are not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that Uniquely Centered Therapeutic Service, LLC is legally required or permitted to make.
3. The Right to Choose How Uniquely Centered Therapeutic Service, LLC Sends Your PHI to You: It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternative method (for example, via email instead of by regular mail). Uniquely Centered Therapeutic Service, LLC is obliged to agree to your request providing that we can reasonably do so.
4. The Right to Get a List of the Disclosures: You are entitled to a list of disclosures of your PHI that Uniquely Centered Therapeutic Service, LLC has made. The list will not include uses or disclosures to which you have specifically authorized (i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family); neither will the list include disclosures made for national security purposes, or to corrections or law enforcement personnel. The request must be in writing and state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. Uniquely Centered Therapeutic Service, LLC will respond to your request within 60 days of receiving your request. The list will include the date of the disclosure, the recipient of the disclosure (including address, if known), a description of the information disclosed, and the reason for the disclosure. Uniquely Centered Therapeutic Service, LLC will provide the list to you at no cost, unless you make more than one request in the same year, in which case it will charge you a reasonable sum based on a set fee for each additional request.
5. The Right to Amend Your PHI: If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that Uniquely Centered Therapeutic Service, LLC correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of Uniquely Centered Therapeutic Service, LLC's receipt of your request. Uniquely Centered Therapeutic Service, LLC may deny your request, in writing, if it finds that the PHI is: (a) correct and complete, (b) forbidden to disclose, (c) not part of its records, or (d) written by someone other than Uniquely Centered Therapeutic Service, LLC. The denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and Uniquely Centered Therapeutic Service, LLC's denial be attached to any future disclosures of your PHI. If Uniquely Centered Therapeutic Service, LLC approves your request, it will make the change(s) to your PHI. Additionally, Uniquely Centered Therapeutic Service, LLC will tell you that the changes have been made and will advise all others who need to know about the change(s) to your PHI.
6. The Right to Get This Notice by Email: You have the right to get this notice by email. You have the right to request a paper copy of it as well.
VIII. Complaints
If you are concerned that your privacy rights may have been violated, or if you object to a decision Uniquely Centered Therapeutic Service, LLC made about access to your PHI, you are entitled to file a complaint. You may also send a written complaint to the Secretary of the Department of Health and Human Services Office for Civil Rights. Uniquely Centered Therapeutic Service, LLC will provide you with the address upon request. Under no circumstances will you be penalized or retaliated against for filing a complaint.
I understand and agree to the HIPPA Privacy Notice outlined above.

Section 19: Mental Health Clients Rights & Grievance Procedure
As a client receiving services from Uniquely Centered Therapeutic Service, LLC, you are guaranteed specific rights under Ohio law. Please review your rights, responsibilities, and our grievance protocol carefully:
1. The right to be treated with consideration and respect for personal dignity, autonomy, and privacy.
2. The right to service in a humane setting which is the least restrictive, feasible environment as defined in the treatment plan.
3. The right to be informed of one's own condition, of proposed or current services, treatment or therapies, and of alternatives.
4. The right to consent to or refuse a service, treatment, or therapy upon full explanation of the expected consequences of such consent or refusal. A parent or legal guardian may consent to or refuse any service, treatment, or therapy on behalf of a minor child.
  - In accordance with Section 5122.04 of the Ohio Revised Code, mental health services (excluding the use of medication) may be provided to minors 14 years of age or older for not more than 6 sessions or 30 days, whichever occurs first, without the knowledge or consent of a parent or guardian.
5. The right to have and receive a copy of a current, written, individualized service plan that addresses one's own mental health, physical health, social, and economic needs and that specifies the provision of appropriate adequate services, as available, either directly or by referral.
6. The right to active and informed participation in the establishment, periodic review, and reassessment of the service plan.
7. The right to freedom from unnecessary or excessive medication, and to be free from restraint or seclusion unless there is immediate risk of physical harm to self or others.
8. The right to be informed of and the right to refuse any unusual or hazardous treatment procedures.
9. The right to participate in any appropriate and available service, regardless of refusal of one or more other services, treatments, or therapies, or regardless of
  relapse from earlier treatment in that or another service, unless there is a valid and specific necessity which precludes and/or requires the client's participation in another service. This necessity shall be explained to the client and written in the client's current service plan.
  
  10. The right to be advised of and refuse observation by techniques such as one-way vision mirrors, tape recorders, television, movies, or photographs.
  
  11. The right to have the opportunity to consult with independent treatment specialists or legal counsel, at one's own expense.
  
  12. The right to confidentiality of communications and of all personally identifying information within the limitations and requirements of disclosure of various funding and/or certifying sources, state or federal statutes, unless release of information is specifically authorized by the client, a parent/legal guardian of a minor, or a court-appointed guardian of an adult client in accordance with rule 5122-2-3-11 of the Administrative Code and 42 CFR.
  
  13. The right to have access to one's own client record unless access to certain information is restricted for clear treatment reasons. If access is restricted, the treatment plan shall include the reason for the restriction, a goal to remove the restriction, and the treatment being offered to remove the restriction.
  
  14. The right to be informed a reasonable amount of time in advance of the reason for terminating participation in a service, and to be provided a referral, unless the service is unavailable or not necessary.
  
  15. The right to receive an explanation of the reasons for denial of service.
  
  16. The right not to be discriminated against in the provision of service on the basis of religion, race, color, creed, sex, national origin, age, sexual orientation, lifestyle, physical or mental handicap, developmental disability, or the inability to pay.
  
  17. The right and freedom to express and practice religious and spiritual beliefs.
  
  18. The right to know the cost of services.
  
  19. The right to fair treatment and consistent enforcement of program rules and expectations.
  
  20. The right to receive hands-off, non-violent crisis intervention and de-escalation strategies.
  
  21. The right to be fully informed of all rights and to receive a written copy upon request.
  
  22. The right to exercise any and all rights without reprisal in any form, including continued and uncompromised access to service, except that no right extends so far as to supersede health and safety considerations.
  
  23. The right to file a grievance.
  
  24. The right to have oral and written instructions for filing a grievance, and to assistance in filing a grievance if requested.
  
  25. The right not to be discriminated against for receiving services on the basis of ethnicity.
  
  26. The right not to be discriminated against for receiving services on the basis of genetic information.
  
  27. The right not to be discriminated against for receiving services on the basis of human immunodeficiency virus (HIV) status.
  
  28. The right to reasonable protection from physical, sexual, or emotional abuse and inhumane treatment.
  
  29. The right not to be discriminated against for receiving services in any manner prohibited by local, state, or federal laws.
  
  30. The right not to be discriminated against for receiving services in any manner prohibited by local, state, or federal laws.

Section 20: Client Responsibilities
To ensure your therapeutic process is safe, structured, and successful, we ask that you actively commit to the following operational and clinical responsibilities:
1. Scheduling: Set and attend scheduled appointments with your therapist consistently.
2. Legal Documentation: Provide a copy of legal custody or guardianship papers at your very first appointment and immediately report if custody or guardianship changes.
3. Financial Commitment: Pay all session or administrative fees that are due.
4. Transparency: Provide accurate and thorough information about your physical and mental health history.
5. Collaborative Planning: Help plan, revise, and actively follow through with your treatment goals.
6. Progress Updates: Keep your therapist informed about any changes in your day-to-day condition and your progress toward meeting your goals.
7. Open Feedback: Report honestly to your therapist if you are dissatisfied with services or if you feel your current treatment is ineffective for you.
I understand and accept my structural and collaborative responsibilities as a client.

Section 21: Client Grievance Procedure
The following administrative procedure is based on the principle that clients must have a clear way to file a grievance within the practice structure. This procedure is available to all clients. Contacting Your Client Rights Officers (CRO):

If you wish to file an internal grievance, you may contact our designated Client Rights Officers, LaDrina Eves or co-owner Joseph Eves Jr.
- Phone: 513-572-5779
- Address: 1325 East Kemper Road, Suite #115, Cincinnati, OH 45246
- Available Hours: Monday – Friday, 9:00 a.m. – 6:00 p.m.
STEP I: Informal Verbal Grievance
If you are dissatisfied with your therapist or have any concerns, a grievance may be made verbally. Your therapist will then be responsible for documenting a written statement of the grievance. This written statement must be signed and dated by the client or include an attestation by a client advocate that it is a true and accurate representation of your concern. Please include the date, approximate time, a description of the incident, and names of individuals involved, if available.
STEP II: Formal Written Escalation
A grievance regarding any practice procedure or policy should be brought to the attention of our identified CRO (who is not your primary therapist) in writing. Uniquely Centered Therapeutic Service, LLC will issue a formal resolution decision on the grievance within 21 calendar days of receipt.
- Acknowledgment: A written acknowledgment of receipt will be provided to you within 3 business days from receipt of the grievance. This includes the date received, a summary of the concern, an overview of our investigation process, a completion timetable, and our contact details.
- Extensions: If extenuating circumstances require an extension beyond 21 calendar days, the reasons will be formally documented in your file, and you will receive written notification.
STEP III: External Rights Organizations
Regardless of whether your internal concern is resolved, you maintain the right to terminate your counseling relationship and/or file an official complaint with any of the following oversight organizations at any time:
- Ohio Department of Mental Health & Addiction Services
  30 East Broad St, 36th Floor, Columbus, OH 43215 | (614) 466-2596 [2]
- Ohio Counselor, Social Worker and Marriage and Family Therapist Board
  77 South High Street, 24th Floor, Columbus, Ohio 43215 | (614) 466-0912 [1]
- Disability Rights Ohio
  200 S. Civic Center Dr, Suite 300, Columbus, OH 43215 | (614) 466-7264
- U.S. Department of Health and Human Services (Office for Civil Rights)
  233 N. Michigan Ave, Suite 1300, Chicago, IL 60601 | (312) 353-1385
- Hamilton County Mental Health & Recovery Services Board
  2350 Auburn Avenue, Cincinnati, Ohio 45219 | (513) 946-8600
I have read and understand my rights regarding the internal and external Client Grievance Procedure.

Section 22: Telehealth Informed Consent
Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (such as secure internet video or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care.By checking the box below, I understand and agree to the following terms:
1. Right to Confidentiality: I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the Disclosure Statement I received from my therapist also apply to virtual services.
2. Technology Risks: I understand that there are technical risks associated with participating in Telehealth. Despite reasonable efforts and security safeguards on the part of my therapist, virtual sessions and data transmissions could be disrupted or distorted by technical failures, or accessed by unauthorized persons.
3. Communication Nuances: I understand that miscommunication or a lack of non-verbal cues between myself and my therapist may occasionally occur via Telehealth.
4. Client Responsibility for Privacy: I understand that there is a risk of being overheard by persons near me. I am entirely responsible for conducting my sessions from a location that is private, secure, and free from distractions or intrusions.
5. Identity & Location Verification: I understand that at the beginning of each Telehealth session, my therapist is legally required to verify my full name and my current physical location.
6. Clinical Suitability: I understand that Telehealth may not always be as effective as in-person therapy. If my therapist believes I would be better served by in-person care, they will discuss this with me and provide an appropriate referral. If coming to our office is impossible due to distance or hardship, I will be referred to local roviders in my area.
7. No Guarantees: While Telehealth is highly effective for a wide range of mental and emotional issues, there is no guarantee that it is effective for all individuals. Results cannot be guaranteed or assured.
8. No Unauthorized Recording: I understand that some Telehealth platforms allow for video or audio recording. Neither I nor my therapist may record any portion of our sessions without the express, written permission of the other party.
9. Billing & Fees: I agree that my therapist will bill my insurance or managed care plan for Telehealth services, and that I will be responsible for any standard portion that my plan mandates (such as co-payments or deductibles), as outlined in the Fees and Billing section of this packet. (Note: Ohio Medicaid plans cover telehealth sessions with $0 out-of-pocket costs).
10. Emergency Protocols: I understand that my therapist will make reasonable efforts to help me identify emergency resources in my geographic area. However, because my therapist is remote, they may not be able to physically assist me in an immediate crisis. If I require emergency care, I will call 911 or proceed to the nearest hospital emergency room.
I have read, understand, and agree to the Telehealth Informed Consent terms.

Section 23: Comprehensive Acknowledgment & Agreement
By checking the box below and providing your electronic signature, you acknowledge that you have read, understood, and voluntarily agree to all the terms, policies, disclosures, and procedures outlined throughout this comprehensive intake packet for Uniquely Centered Therapeutic Service, LLC. Your signature confirms your specific agreement to:
- The Strength-Based Clinical Evaluation & Triage process.
- The Financial, Insurance Billing, and 24-Hour Cancellation Policies
- The Therapist Credentials, Ethical Guidelines, and Clinical Supervision Structure.
- The Clinical Risks and Benefits of the Counseling Process.
- The Limits of Confidentiality, Privacy Protections, and Secure Record Keeping Protocols.
- The Therapist Absence, Emergency Continuity of Care, and Contact Policies.
- The Session Expectations, Mutual Respect Guidelines, and Planned Termination Process.
- The 30 Mandated Mental Health Client Rights & Responsibilities under Ohio Law.
- The 3-Step Internal and External Client Grievance Procedure.
- The HIPAA Notice of Privacy Practices and federal PHI guidelines.
- The Telehealth Informed Consent and virtual care boundaries (if applicable).
You acknowledge that you have had the opportunity to ask questions regarding these policies and that they have been answered to your satisfaction. You understand that a digital copy of this signed agreement is available to you at any time upon request.
Client Signature (or Parent/Legal Guardian if client is a minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Uniquely Centered Therapeutic ServiceClient Intake Application

Section 1: Care Preference

Section 2: Address & Secure Contact Preferences

Emergency Contact

Section 3: Connection & Community Referral

Section 4: Strengths & Client History

Coping Tool Kit

Areas for Support and Relief

The Destination

Past Therapy History

Section 4: Medical History, Safety Tracking, & Background

Medical Conditions

Medications

Medical Providers

Section 5: Safety and Crisis Tracking

Self-Harm Tracking

Section 6: Family, Marital, & Social Background

Home Environment

Family Mental Health History

Section 7: Legal History & Support

Section 8: Fees, Billing, & Informed consent

Coverage Type

Section 9: Protecting Out Time Together (Cancellation Policy)

Section 10: Credentials, Professional Organizations, and Ethics

Section 11: Risk and Benefits of the Counseling Process

Section 12: Privacy & Limits to confidentiality

Section 13: Record Keeping & Documentation

Section 14: Therapist Inability to Render Care & Continuity of Care

Section 15: Contacting Your Therapist & Managing Appointments

Section 16: Session Expectations & Mutual Respect

Section 17: Termination of Care & Ongoing Support

Section 18: Health Insurance Portability and Accountability Act (HIPPA)

I. Commitment to Your Privacy

II. Legal Duty to Safeguard Your PHI

III. Changes to This Notice

IV. How Uniquely Centered Therapeutic Service, LLC May Use and Disclose Your PHI

V. Use and Disclosure of Your PHI in Certain Special Circumstances

VI. Other Uses and Disclosures Require Your Prior Written Authorization

VII. Rights You Have Regarding Your PHI

VIII. Complaints

Section 19: Mental Health Clients Rights & Grievance Procedure

Section 20: Client Responsibilities

Section 21: Client Grievance Procedure

STEP I: Informal Verbal Grievance

STEP II: Formal Written Escalation

STEP III: External Rights Organizations

Section 22: Telehealth Informed Consent

Section 23: Comprehensive Acknowledgment & Agreement