Program Enrollment (TS Counseling and Consultation, Inc.)

Welcome

TS Counseling & Consultation, Inc.
Welcome, and thank you for considering TS Counseling & Consultation, Inc. for your care.

Before enrolling, please review the Program Information documents.
These explain what services are offered, how they work, what they cost, and what your rights are.

Be sure to get all the information you need to make your decision. If you have questions, ask your provider.

Use this information to help you decide whether services at TS Counseling & Consultation, Inc. are a good fit for you.
Please note the following:

⚠️ Time Required: Please set aside at least 30 uninterrupted minutes to complete this form.

⚠️ No Save Option: This form does not allow saving your progress. If you close your browser before submitting, you will need to start over.

⚠️ One-Time Submission: After you submit, you will not be able to access or edit your form.

Record Keeping: Your responses will be stored securely as part of your confidential client record.

Security and Privacy: This form is HIPAA-compliant. Your personal information is encrypted and protected.

Confirmation Message: You will know that your forms are complete when you see a Thank You message at the end. This means your form was submitted successfully.

Program Information Documents

TS Counseling & Consultation, Inc.
Please read the documents carefully before advancing.

Download and save these materials for your personal records.

If you have any questions, please do not advance. Instead, please contact:

Tom Shrewsbury
TS Counseling & Consultation, Inc.
Phone: (503) 820-9666
Select your state of residence*

CaliforniaColoradoNew MexicoOregonTexasWashington
Program Information*
Crisis support and helpline services*
Notice of Privacy Practices*
Professional Disclosure Statement (Tom Shrewsbury, PhD)*
California Residents: LCSW License (J. Tom Shrewsbury, PhD)*
Colorado Residents: LCSW License (Tom Shrewsbury, PhD)*
New Mexico Residents: LCSW License (Tom Shrewsbury, PhD)*
Oregon Residents: LCSW License (Tom Shrewsbury, PhD)*
Texas Residents: LCSW License (Tom Shrewsbury, PhD)*
Washington Residents: LCSW License (Tom Shrewsbury, PhD)*

Do you have any questions about the information in these materials?*

YesNo
You indicated that you have questions about information in the program information documents.

Please do not click next.

Instead, close your browser and contact:

Tom Shrewsbury
TS Counseling & Consultation, Inc.
Phone: 503-820-9666
You indicated that you do not have questions about the information in the Program Information documents.

Your provider will review parts of this information with you during your first session and again as needed.

If you have questions at any time, please ask your provider.

Click “Next” to continue to the Informed Consent Acknowledgement.

Informed Consent Acknowledgement

TS Counseling & Consultation, Inc.
This form may be signed electronically in compliance with applicable state and federal laws.

Electronic signatures and electronic initials carry the same legal weight as handwritten signatures under applicable state and federal law.
Please enter today's date*

MonthDayYear
Date
Client's full legal name (include full middle name; NO nicknames please)*

First NameMiddle NameLast Name
Client's lived name or nickname (if different than legal name)*

First NameLast Name
Client's date of birth*

MonthDayYear
Date
Pronouns (mark all that apply)*

She/her/hersHe/him/hisThey/them/theirsOther
Complete home address (include apartment or suite # if applicable)*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please re-enter your email*
example@example.com

CONSENT TO RECEIVE PSYCHOTHERAPY/COUNSELING SERVICES

My initials below I acknowledge that prior to signing this informed consent acknowledgement:
- I have received and reviewed the TS Counseling & Consultation Inc. Program Information document
- I have had the opportunity to ask questions before starting services and have received answers to my satisfaction.
- I understand the information which includes but is not limited to:
  - Psychotherapy/counseling services
  - Therapeutic approaches and techniques
  - Purpose of, intended benefits, possible risks, and alternatives to psychotherapy/counseling services
  - Potential risks of not taking part in psychotherapy
  - Fees, payment policies, and insurance information
  - Confidentiality policies and exceptions
  - Emergency procedures and crisis planning
  - Conditions under which services end
  - Client rights and responsibilities
  - Complaint procedures and licensing board contacts
  - Legal services policies and limitations
  - Client protections under the No Surprises Act
-----

My initials below confirm that I have read, understood, and agree to the information summarized in this section and detailed in the TS Counseling & Consultation Inc. Program Information document.
Clear
Date*

MonthDayYear
Date

I understand that:
- My participation in psychotherapy/counseling is voluntary.
- I may withdraw my consent at any time without obligation or harassment.
- No guarantees can be made regarding specific outcomes or timelines.
- I understand that my information is kept confidential except in specific situations including but not limited to:
  - Imminent danger to self or others
  - Suspected abuse or neglect of minors, elders, or dependent adults
  - Medical emergencies
  - Court orders (not subpoenas)
  - Disclosures necessary for coordination with your insurance or EAP provider, in compliance with HIPAA privacy rules
  - Consultation with other professionals to ensure quality of my care
- TS Counseling & Consultation, Inc. does not provide crisis response between sessions
- In the event of a psychiatric emergency, I will contact 911 or call the 988 Suicide & Crisis Lifeline
-----

My initials below confirm that I have read, understood, and agree to the information and terms summarized in this section and detailed in the TS Counseling & Consultation Inc. Program Information document, including the limits of confidentiality, my rights to withdraw, and the procedures in place for emergencies.
Clear
Date*

MonthDayYear
Date

FEES

TS Counseling & Consultation Inc.’s fees are as follows:

Psychotherapy Session Fees:
- Individual sessions: $200
- Couples/family sessions: $250
- Exception: Charges are reduced only if my provider agrees to a sliding-fee scale arrangement.
EAP Session

Individual, couples, and family EAP counseling:
- $0 for attended appointments
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My initials below confirm that I have reviewed the fee information provided above, understand the cost of services, and I agree to the stated fees.

I understand that any reduced rate applies only if my provider agrees to a sliding-fee arrangement in advance.

I acknowledge that additional details about fees, payment policies, and financial terms are outlined in the TS Counseling & Consultation Inc. Program Information document.
Clear
Date*

MonthDayYear
Date

Payment Policy

TS Counseling & Consultation, Inc.’s payment policy is shown below.

This applies to all clients, including those receiving a sliding-scale fee arrangement.
- Full payment is due at the time of service
- I am responsible for all charges not covered by insurance, EAP, HSA/HRA, or other benefits
- Appointments will not be scheduled if there is an outstanding balance
- Refunds are not issued for services already rendered
- TS Counseling & Consultation Inc. may pursue reasonable and lawful means to collect unpaid fees and charges, including use of third-party collection services if necessary.
-----

My initials below confirm that I have read, understood, and agree to the payment policy described above.

I understand that I am responsible for all charges not covered by third-party payers, and that services may be paused if my account has an outstanding balance.

I acknowledge that TS Counseling & Consultation Inc. may take reasonable and lawful steps to collect unpaid fees if necessary.

Additional information about payment expectations and procedures is detailed in the TS Counseling & Consultation Inc. Program Information document.
Clear
Date*

MonthDayYear
Date

LATE ARRIVALS, MISSED APPOINTMENTS, AND LATE CANCELLATIONS

TS Counseling & Consultation Inc.’s policy involving late arrivals, missed appointments, late cancellations, and late reschedules is shown below.

This applies to all clients, including those receiving a sliding-scale fee arrangement.
- Arriving more than 7 minutes late will be considered a no-show and subject to the applicable charge.
Below are the charges you will owe per occurrence if you miss an appointment or cancel/reschedule with less than 24 hours’ notice:
- Psychotherapy clients:
  - $200 per occurrence for individual sessions
  - $250 per occurrence for couples/family sessions
Payment for missed appointments, late cancellations, and late reschedules is due immediately.

Exception to charges for missed appointments, late cancellations, and late reschedules: Fees may be waived only in cases of a medical or psychiatric emergency requiring urgent care within 24 hours of the appointment.
-----

My initials below confirm that I have read, understood, and agree to the late arrival, missed appointment, and late reschedule/cancellation policy summarized above and described above and in the TS Counseling & Consultation, Inc. Program Information document.

I acknowledge that this policy applies regardless of insurance coverage or fee arrangement.

Further details are provided in the TS Counseling & Consultation Inc. Program Information document.
Clear
Date*

MonthDayYear
Date
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My initials below confirm that:

I agree to pay the charges in full for appointments missed or canceled/rescheduled with less than 24 hours’ notice.
Clear
Date*

MonthDayYear
Date

LEGAL SERVICES ACKNOWLEDGMENT

TS Counseling & Consultation Inc.’s policy on legal services is detailed in the Program Information document. This includes but is not limited to:
- TS Counseling & Consultation, Inc. does not provide evaluations or documentation for court, custody, disability cases, or any listed in the Program Information document.
- Legal services require an $8,000 retainer and are billed at $350/hour.
-----

My initials below confirm that I have read, understood, and agree to the legal services policy and fees summarized above and detailed in the TS Counseling & Consultation, Inc. Program Information document.

I understand that TS Counseling & Consultation Inc. does not provide documentation or evaluations for court, custody, disability, or similar matters.

I acknowledge that any legal services require an $8,000 retainer and are billed at $350/hour.

Additional details are provided in the TS Counseling & Consultation Inc. Program Information document.
Clear
Date*

MonthDayYear
Date

Insurance Responsibility Acknowledgment

If using insurance benefits:
- I understand that TS Counseling & Consultation, Inc. is not responsible for verifying my insurance benefits or obtaining authorization for services.
- I understand that insurance coverage is not guaranteed and that reimbursement decisions are made solely by my insurance provider.
- I am responsible for verifying my own coverage including co-pays, deductibles, session limits, and any exclusions.
- I agree to pay all charges not covered by insurance, including charges that are denied, reduced, or applied to my deductible.
- I understand that non-payment by insurance does not relieve me of responsibility for payment.
-----

By initialing below, I confirm that I have read and understood the Insurance section of the TS Counseling & Consultation, Inc. Program Information document.

I accept TS Counseling & Consultation, Inc.'s policy terms including but not limited to verifying my insurance coverage and paying for all charges not paid by my insurance provider.
Clear
Date*

MonthDayYear
Date
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My initials confirm that I understand that clients using insurance agree to:

Notify TS Counseling & Consultation, Inc. in writing within three (3) business days when in-network insurance coverage changes or ends.
Clear
Date*

MonthDayYear
Date

INFORMED CONSENT CONFIRMATION

By signing below, I confirm that:
- I have received, read, and understand the information provided in the following documents:
  - Program Information document
  - My provider's Professional Disclosure Statement
  - My provider's professional license
  - Notice of Privacy Practices
  - List of Crisis Resources
- I have had the opportunity to ask questions before starting services and have received answers to my satisfaction
- I understand and agree to all fees, payment policies, and financial terms outlined in the Program Information document
- I understand that psychotherapy/counseling with TS Counseling & Consultation, Inc. is a voluntary outpatient service and is not a substitute for emergency medical or psychiatric care
- I understand my rights and responsibilities as a client
- I voluntarily consent to participate in psychotherapy/counseling services with TS Counseling & Consultation, Inc.
- I understand I may request clarification or withdraw consent at any time without obligation or harassment.
- I understand that I may request access to my records, as permitted by law.
- I understand that services will be discontinued if clinically appropriate or if any of the conditions described in the “When Do Services End?” section of the Program Information document apply.
- This informed consent covers psychotherapy and EAP services only. I agree to pay any unpaid fees or charges, regardless of the reason services ended.
- Consent to psychotherapy/counseling services remains valid while I am actively receiving care, unless I withdraw my consent.
-----

My signature below affirms the following:

I have read, understood, and agree to all of the above terms, including those related to insurance, payment, cancellations, and
responsibilities as an in-network insurance client, if applicable.

I acknowledge that this consent form and the Program Information document together form the basis of my agreement with TS Counseling & Consultation, Inc.

I understand that this informed consent does not constitute a guarantee of treatment or ongoing availability of services and that continued participation is contingent upon clinical appropriateness and mutual agreement.
Client's full legal name (include full middle name; NO nicknames please)*

First NameMiddle NameLast Name
Client's Signature*

Clear
Date*

MonthDayYear
Date

Services Delivered via Telehealth

TS Counseling & Consultation, Inc.
Details about service delivery via telehealth were provided in the Program Information document that you received and reviewed.

Please indicate whether you would like to proceed with signing the Informed Consent Acknowledgement for services delivered via telehealth.
Would like to proceed with the Informed Consent Acknowledgement to receive psychotherapy/counseling services via telehealth?*

YesNo

Informed Consent Acknowledgement to Receive Psychotherapy/Counseling Services via Telehealth

TS Counseling & Consultation, Inc.
This form may be signed electronically in compliance with applicable state and federal laws.

Electronic signatures and electronic initials carry the same legal weight as handwritten signatures under applicable state and federal law.
I acknowledge that I:
- Have received, reviewed, and understand the information provided in the Program Information document, which includes an explanation of the purpose, benefits, risks, and alternatives to telehealth.
- Understand that TS Counseling & Consultation, Inc. takes reasonable precautions to ensure privacy and security but cannot guarantee protection from third-party risks (e.g., internet service providers, email and phone carriers, etc.).
- Understand that my provider will use Zoom for telehealth sessions, and that TS Counseling & Consultation, Inc. has a signed Business Associate Agreement with Zoom and uses the platform in accordance with HIPAA requirements.
- Have been provided access to Zoom’s Terms of Service and Privacy Policy, and understand I am encouraged to review these before the first session for informational purposes.
- Have been informed of and understand TS Counseling & Consultation, Inc.’s emergency procedures, my rights and responsibilities while receiving telehealth services, and limitations of emergency care during telehealth sessions.
- Understand that all emails and text messages sent to or received from TS Counseling & Consultation, Inc.—including non-secure communications—become part of my official clinical record.
  - Exception: Communications containing sensitive information will be sent and received only through the provider’s HIPAA-secure encrypted email system.
- Have had the opportunity to ask questions and receive clarification before starting services via telehealth.
I understand that:
- Receiving services via telehealth is voluntary.
- I may withdraw consent to receive services via telehealth at any time without penalty. This will not affect my services or access to other forms of care.
- If telehealth is determined to no longer be clinically appropriate (such as when in-person assessment is required, when safety concerns arise, or when technical limitations interfere with effective treatment), or if legal restrictions change, my provider will discuss alternative options for care or refer me to an appropriate in-person provider.
- I understand that telehealth is not suitable for psychiatric emergencies.
  - If an emergency arises, I will call 911 or seek immediate in-person care.
  - If I have a medical or psychiatric emergency during a session, my provider will coordinate emergency services but cannot provide in-person emergency intervention during telehealth sessions.
- All HIPAA confidentiality rules apply to telehealth sessions.
- Sessions can be recorded only with my written permission. If a session is recorded, I will be informed of this before the recording starts.
- I am responsible for my own internet, device, and technology costs.
- TS Counseling & Consultation, Inc. is not responsible for service disruptions, platform outages, or loss of access due to technical issues or internet service problems that are outside the provider’s control.
- Consent to receiving services via telehealth remains valid while I am actively receiving care, unless I withdraw it. If I resume services after a break, I understand that a new consent may be required.
By initialing below, I confirm that I have read and understood the Consent to Receive Psychotherapy/Counseling Services via Telehealth section in the TS Counseling & Consultation, Inc. Program Information Document. I agree to the terms and policies governing the use of telehealth services as outlined.*

Clear
Date*

MonthDayYear
Date

Technology Limitations and Risks

My initials below affirm that:
- I understand that TS Counseling & Consultation, Inc. takes reasonable steps to protect my information and uses secure platforms that comply with HIPAA standards. However, no electronic communication is completely secure.
- I acknowledge that my data may be subject to access, collection, or use by third parties (such as internet service providers, email platforms, mobile carriers, or hackers) that are outside the control of TS Counseling & Consultation, Inc. I understand that my provider cannot guarantee protection from unauthorized access, data breaches, or misuse of information by external parties.
- I accept these risks as inherent in the use of telehealth technologies and agree to take reasonable steps on my end to protect my own privacy (e.g., using secure networks, updating device security, logging out after sessions, etc.).
Clear
Date*

MonthDayYear
Date

My initials below confirm that I agree to the following:

I will be physically located in a state where my provider is licensed during sessions.
Clear
Date*

MonthDayYear
Date
My initials below confirm that I agree to the following:

I will inform my provider in advance of any change in location.
Clear
Date*

MonthDayYear
Date
My initials below confirm that I agree to the following:

I will not operate a vehicle during sessions.
Clear
Date*

MonthDayYear
Date
My initials below confirm that I agree to the following:

I will be dressed appropriately and attend from a private space free of distractions.
Clear
Date*

MonthDayYear
Date

My signature below confirm that:

I consent to receive psychotherapy/counseling services via telehealth.

I may revoke this consent (virtual sessions) at any time without penalty.
Clear
Date*

MonthDayYear
Date
My signature below confirm that:

I consent to receive non-secure texts and non-secure emails for non-sensitive matters such as scheduling, links to forms and meetings, and payment reminders.

I may revoke this consent (non-secure texts and non-secure emails) at any time without penalty.
Clear
Date*

MonthDayYear
Date
My signature below confirm that I consent to:

Receive and send communications for sensitive matters via HIPAA-protected email used by TS Counseling & Consultation, Inc.

I may revoke this consent (HIPAA-protected emails) at any time without penalty.
Clear
Date*

MonthDayYear
Date

Video Recording Sessions

TS Counseling & Consultation, Inc.
Our practice is to video record psychotherapy/counseling sessions for the purpose of enhancing clinical care with your permission.

Reviewing session recordings allows your provider to observe details that may have been missed and to bring these insights into future sessions to support your progress.

Your provider will also show brief excerpts of recordings to experienced supervisors or professional colleagues to get guidance on what they can do to better support you.

All individuals who view session recordings are bound by professional confidentiality standards. In addition, professional viewers comply with applicable federal and state laws governing your privacy.
Would you be willing to allow your provider to video record your sessions so that you can get the best care possible?*

YesNo

Informed Consent Acknowledgement to Video Record Psychotherapy/Counseling Sessions

TS Counseling & Consultation, Inc.
This form may be signed electronically in compliance with applicable state and federal laws.

Electronic signatures and electronic initials carry the same legal weight as handwritten signatures under applicable state and federal law.
CONSENT TO VIDEO RECORDING PSYCHOTHERAPY/COUNSELING SESSIONS

My initials below confirms that I have:
- Reviewed the TS Counseling & Consultation, Inc. Program Information document and understand the purpose, benefits, and risks of session recordings.
- Been informed that recordings are only viewed by my provider, the provider’s supervisors, clinical consultants, or other approved professionals who have a legitimate professional need and are bound by confidentiality laws.
- The right to request that recordings of me be deleted without affecting my care.
I understand that:
- Video recording of my sessions is voluntary.
- I may withdraw my consent to video record at any time without affecting my care.
- Recordings will be retained for no longer than 12 months unless earlier deletion is requested.
  - Upon verbal or written request, recordings will be deleted within 3 business days.
- Recordings may be disclosed without my written consent only when legally required or permitted—such as to licensing boards, oversight bodies, EAP vendors (but not employers), or legal counsel in the event of a formal complaint, court order, investigation, or legal action related to my care or to my provider’s conduct.
- Consent to video recording remains valid while I am actively receiving care, unless I withdraw it.
- My provider may invite me to view a recording if they believe it will assist me in achieving my psychotherapy/counseling goal.
- Recordings will never be posted online or used for marketing.
My initials below confirm that I voluntarily consent to recording for clinical purposes to help improve the quality of care I receive.
Clear
Date*

MonthDayYear
Date

Use of Recordings for Teaching and Training Purposes

We invite you to consider giving your provider permission to use video recordings of your sessions for teaching and training purposes. Your real experiences in therapy teach helping professionals things they can't learn from books - how to truly connect with clients, what actually works, and how healing really happens. When you allow your sessions to be recorded for training, you are helping create better clinicians for people who seek help.
Would you be willing to allow your provider to use video recordings for educational purposes so that current and future mental health professionals can deliver effective psychotherapy/counseling services?*

YesNo
My initials below confirm that I voluntarily consent to recording for teaching and training purposes to help students and professionals learn how to deliver high-quality psychotherapy/counseling services.
Clear
Date*

MonthDayYear
Date

Client Questionnaire

TS Counseling & Consultation, Inc.
Thank you for signing the Informed Consent Acknowledgment forms.

Next step:

Please complete the following questionnaire. The information you provide will help us plan and tailor your care effectively.

Be sure to complete the entire questionnaire.

You will know it has been successfully submitted when you see the Thank You page at the end.

To ensure that our records are accurate, please review the information below carefully.

If you notice any errors, please correct them before proceeding.
Please enter today's date*

MonthDayYear
Date
Client's full legal name (include full middle name; NO nicknames please)*

First NameMiddle NameLast Name
Client's date of birth*

MonthDayYear
Date
I have reviewed my information and confirm it is accurate.

Medical Emergency Information
Emergency Safety Information

TS Counseling & Consultation, Inc. has a legal, ethical, and moral responsibility to ensure that you receive immediate help if a medical emergency occurs during your appointment.

To support your safety, please provide the following:
- The name and phone number of your emergency contact
- The name and location of the nearest emergency room
Details about how to access the building or space where you will be during your sessions (if meeting by telehealth)

Having this information on file allows your provider to respond quickly and appropriately if an emergency arises. Your safety is our top priority.
Emergency contact name*

First NameLast Name
What is the relationship of your emergency contact? (e.g. spouse, partner, parent, sibling, etc.)*
Emergency Contact's Phone Number*
Please enter a valid phone number.
Full name of the Emergency Department that is nearest to the address where you will be when you are attending telehealth counseling appointments*
Complete address of the Emergency Department*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number of the Emergency Department*
Please enter a valid phone number.
Emergency Access Information

To help emergency medical services reach you quickly and safely, please provide any important information about your residence, including:
- Gated community or security system access
- Entry codes or gate codes needed for access
- Pets on the property
- Parking restrictions or limited access areas
- Stair-only entry, narrow pathways, or construction zones
- Any other access-related details that could affect emergency response
If there are no access restrictions, please write “None.”

Providing this information helps ensure a prompt and effective emergency response if ever needed.

Information about Current Problem
What problem would you like help with? *
On a scale of 0 to 10 (with 10 being the highest), how distressing is the problem for you right now?*
How long have you been experiencing this problem?*
What caused this problem?*
What keeps the problem going, in your opinion?*
What have you done to resolve this problem so far?*
What happened recently that made you seek professional help right now?*

Rows	Not at all	Several days	More than half the days	Nearly every day
Thoughts that you would be better off dead, or of hurting yourself

Please describe the people who are important to you—these may be family members, friends, partners, mentors, or anyone else who plays a meaningful role in your life.

Provide details including:
- Who they are (e.g., my grandmother, my best friend, my partner)
- What makes them important to you or how they support you
- How often you connect with them
Please describe any people in your life with whom you are currently experiencing conflict (such as family members, partners, friends, coworkers, etc.).

Provide details including:
- Who the conflict is with (e.g., my sister, my supervisor)
- The main reasons or sources of tension
- How the conflict affects you
Please describe your current living situation including who lives with you. *
Please mark all that apply.*

I work full-timeI work part-timeI am in school full-time or part-time timeI am retiredNone of the above
Work and Workplace
- What type of work do you do?
- Do you like about your job for the most part?
- What do you like about your work?
- What don't you like about your work?
- What words describe your workplace?
School and Education
- What are you studying?
- Do you enjoy school?
- How much longer do you have until you complete your program?
Please describe what a typical day looks like for you.
Are you CURRENTLY involved in any LEGAL MATTERS?*

YesNo
Please describe how current legal involvement is affecting your emotional well-being, stress levels, or ability to focus on other areas of your life.
Have you been involved in LEGAL MATTERS in the PAST?*

YesNo
Please share whether past legal involvement is affecting your current emotional well-being, stress levels, or ability to focus on other areas of your life.
Please share anything else you would like your provider to know that would help you receive the best care possible.*

Click “Submit” to complete this form.

Please wait until see the Thank You message.
Should be Empty:

Rows	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen

Rows	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual

Rows	Yes	No
Have you used substances or drugs other than those required for medical reasons?
Do you use more than one substance or drug at a time?
Do you find it difficult to quit using substances or drugs even when you have the desire to do so?
Have you ever had blackouts or flashbacks as a result of your substance or drug use?
Do you ever feel bad or guilty about your substance or drug use?
Do loved ones (partner, spouse, parents, siblings, friends, etc.) ever complain about your use of substances or drugs?
Have you neglected your family because of your use of substances or drugs?
Have you engaged in illegal activities in order to obtain substances or drugs?
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking substances or drugs?
Have you had medical problems as a result of your substance or drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?

Rows	Concerns me	Concerns someone else	N/A
Angry outbursts
Caffeine use
Comparing myself to others who appear happier or wealthier than me
Driving after drinking alcohol or ingesting mind/mood altering substances (including cannabis, medications, or drugs)
Eating habits (overeating, anorexia, bulimia)
Excessive working
Gambling
Hoarding
Internet use
Lying
Over-exercising
Pornography
Preoccupation with appearance or weight
Self-harm (cutting, burning, scratching, hitting yourself)
Sexual behavior
Shopping or spending money
Social isolation
Social media
Tobacco use (including cigarettes, chew/spit/SNUS, e-cigs, vaping)
Unsafe driving or road rage
Video gaming
Watching television
Watching the news

Welcome

Program Information Documents

Informed Consent Acknowledgement

Services Delivered via Telehealth

Informed Consent Acknowledgement to Receive Psychotherapy/Counseling Services via Telehealth

Video Recording Sessions

Informed Consent Acknowledgement to Video Record Psychotherapy/Counseling Sessions

Client Questionnaire

Medical Emergency Information

Intake Information

Medical Information

Information about Current Problem

Information about Mental Health

Anxiety and Depression

Adverse Childhood Experiences

Cannabis Use

Alcohol Use

Drug Use

Habits of Concern