• Active Parenting

    Participation Agreement & Consent for Services

  • Welcome to Family Service Agency's Center for Counseling. the Center for Counseling provides services for all ages through a staff of experienced, diverse licensed counselors, social workers, and marriage/family therapists.

     

     The expectations of the FSA Active Parenting program are as follows:

    • Pre-registration and scheduling is required to attend the 4-or-6 week session/group educational programming as a cost of $0.
    • You must attend and participate in the group sessions. You are provided with a workbook which you must bring to all group sessions.
    • You must call FSA at (815)758-8616 if you are unable to attend a session due to an emergency situation. If you miss ONE group session you MUST retake that session when it is available BEFORE you can attend the next session. TWO or more missed groups may result in immediate termination from the program.
    • If you CANCEL less than 24 hours before the class or are a NO SHOW (DO NOT LOGIN), you will be assessed a $25 RE-SHCEDULING FEE.
    • Courteous behavior is expected. Disruptive individuals will be removed from the virtual/in-person class and will be required to complete the program through a different agency. Cell phone use is prohibited during the program sessions.
    • Active Parenting is a program for adults. Children should not be part of the in-person or virtual online class.
    • Please login or arrive 5-15 minutes prior to the start of your session to adjust for any technical difficulties.
    • If you attempt to join the class after 10 minutes you will not be allowed to enter the class and will need to reschedule for a different date.

    The following events will be treated as infractions of the Active Parenting Program resulting in termination:

    • Two missed sessions
    • Refusal to do at home activities
    • Infraction of rules including verbal threats of violence

    To receive the Certificate of Completion you must:

    • Attend each session in its entirety. Sign-in sheets must be signed to confirm attendance.
    • Provide your case manager information

  • Consent for Services & Financial Agreement

  • I,    *   *    , request services from Family Service Agency's programs.

  • 1. I seek and consent to participate in services at Family Service Agency's programs.

    2. I understand that I may stop program services at any time and that I am responsible for any consequences of terminating services.

    3. I understand and have discussed with my group facilitator: a.) my condition, problem and/or diagnosis, b.) the planned course of treatment, c.) alternatives to treatment, including no treatment and d.) confidentiality and the limits or exceptions of confidentiality.

     

  • Agreement to Pay for Professional Services

  • I,   *   *  , agree to pay the fee described above for these services and any additional fees described below.

  • Additional Charges May Apply:

    • You will be charged a $20 fee for a replacement workbook if yours is lost or damaged beyond use.

    Additional billing policies:

    • Program costs and any incurred fees are out of pocket expenses.
    • If a bill is not paid it may be sent to collections and I will be responsible for the additional 35% charged by the collection agency to collect the bill.
    • I am responsible for giving Family Service Agency updated address information. Failure to do so may result in any unpaid bill being sent to collections.
    • Lack of payment of the sessions may result in being unable to schedule another appointment.
    • Any billing questions should be directed to the Family Service Agency Business Office.

    If you have additional concerns, please contact the Agency for assistance 815-758-8616.

    We will work with you to complete the Active Parenting Program. If you have additional concerns, please contact the Agency for assistance at (815) 758-8616.

    My signature indicates understanding of the expectations for Family Service Agency's Active Parenting program and my agreement to comply with the expectations and billing policies as stated above.

    I understand and agree to the information contained in this Agreement to Pay for Professional Services. If applicable, my signature below authorizes my insurance to make payment directly to Family Service Agency's Center for Counseling.

  • Adult Intake Form

  • Format: (000) 000-0000.
  • Phone type:*
  • Format: (000) 000-0000.
  • Preferred Contact Method:*
  • Add a photo of your current ID

  • Demographic Information

  • Are you Hispanic, Latino/a/x, or Spanish origin?*
  • If yes, check one:
  • Citizenship Status:*
  • Are you a Veteran or Military Service Member?*
  • Do you require an interpreter?*

  • Financial & Household Information:

  • Do you have insurance through your employer?*
  • Add a photo of the front of your insurance card.
  • Add a photo of the back of your insurance card.

  • Treatment History

  • Is the client currently or previously receiving mental health treatment?*
  • Are you willing to sign a release of information form?
  • Is the client currently taking any medications?*
  • Do you have concerns about any of the following?*

  • Adult Symptom Checklist

    Please indicate if you experience any of the following symptoms and how often within the last 3 months you've experienced them.
  • Feelings of Guilt*
  • Worrying*
  • Anger*
  • Problems falling asleep*
  • Problems staying awake*
  • Afraid of leaving the house*
  • Feeling alone*
  • Memory loss*
  • Trouble making decisions*
  • Sudden mood changes*
  • Restlessness*
  • Excessive spending*
  • Hopelessness about the future*
  • Ruminating about the past*
  • Crying excessively*
  • Feeling anxious*
  • Irritable or on edge*
  • Shortness of breath*
  • Problems with gambling*
  • Stomach problems*
  • Lying*
  • Uncontrolled thoughts*
  • Uncontrolled behaviors*
  • Problems getting along with others*
  • Feeling worthless*
  • Excessive spending*
  • Overly tired*
  • Overeating*
  • Bingeing*
  • Food preoccupation*
  • Vomiting*
  • Sleeping too much*
  • Hearing voices*
  • Problems at work*
  • Nightmares*
  • Obsessive thoughts*
  • Thinking about death*
  • Thinking about suicide*
  • Feeling down or blue*
  • Feeling panicky*
  • Phobias/fears*
  • Too much/lack of energy*
  • Blackouts*
  • Physical abuse of self or others*
  • Emotional abuse of self/others*
  • Sexual problems*
  • Relationship problems*

  • Consent to Participate in Telehealth Appointments

  • I,   *   *  , understand the following:

    • My behavioral health professional wishes me to engage in a telehealth consultation using Zoom.
    • My behavioral health professional has provided information needed to make an informed decision about engaging in Zoom technology.
    • I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
    • I understand that my behavioral health professional or I can discontinue the telehealth consult/visit if it is felt that the Zoom videoconferencing connections are not adequate for the situation.
    • I understand that if others are present during the consultation other than my behavioral health professional, they will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: 1.) omit specific details of my medical history/physical examination that are personally sensitive to me; 2.) ask non-medical personnel to leave the telehealth session/room: and or 3.) terminate the consultation at any time.
    • In an emergency, I understand that the responsibility of my behavioral health to contact my listed emergency contact or the local first responders if there is a termination of the Zoom video conference connection.
    • I have had a direct conversation with my behavioral health professional, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits, and any practical alternatives have been discussed with me in a language in which I understand.
  • Please indicate your preference below*

  • By signing this form I certify:

    • I have read or have had this form read/explained to me.
    • I fully understand its contents including the risks and benefits of the procedure(s).
    • I have been given ample opportunity to ask questions and that my questions have been answered to my satisfaction.

  • Release of Information

    If you would like Family Service Agency to be able to share information regarding your services here with an outside agency or individual, please complete the below Release of Information form.
  • Client Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • I hereby give consent to Family Service Agency of DeKalb County, 1325 Sycamore Rd., DeKalb, IL. 60115  (815) 758-8616  to release and/or exchange protected mental health information and/or program information concerning the above-named client in written, oral, or electronically to the following person or entity:

  • Format: (000) 000-0000.
  • Purpose for Releasing Information:
  • Type of Information:

  • **Please note that if Children's Advocay Center: Forensic Interview Disclosure and Services is selected, this only permits discussion of interview with mental health or medical professionals. Records from the Children's Advocay Center will not be released without a judge signed subpoena.

  • I understand that:

    • I have the right to obtain a copy of my own protected health information.
    • I have the right to revoke this authorization at any time, I must do so in writing to the medical records department, I may not revoke for information that has already been authorized and disclosed.
    • Re-disclosure of information is prohibited without written consent, that being stated, Family Service Agency cannot prevent an entity to which it is disclosing to from re-disclosing the information on their own accord.
    • Authorizing to disclose protected health information is voluntary and not required treatment, payment, or benefits.
    • Form must be filled out in its entirety for request to be honored.
    • Fees may be charged for records per all laws applicable to release of protected health information.
    • My record may contain information pertaining to Sexually Transmitted Disease (STD), acquired immunodeficiency syndrome (AIDS), or Human Immunodeficiancy Virus (HIV).

  • Client Acknowledgements

  • Should be Empty: