• Form

  • DAVID HUDSON COUNSELING PERSONAL INFORMATION FORM

    IF YOU ARE FEELING LIKE YOU ARE IN DANGER OF HARMING YOURSELF OR OTHERS RIGHT NOW, STOP AND CALL 911 OR 988 IMMEDIATELY.
  • Today's date*
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  • Date of Birth?*
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    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred form of contact:*
  • Format: (000) 000-0000.
  • Did your prescribing physician educate you on your medications?
  • Do you wish to have us contact your PCP about your treatment with me?
  • Previous counseling?
  • Previous psychiatric hospitalizations?
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  • PROBLEMS WITH (Check as many as apply):*
  • Suicidal thoughts:*
  • Homicidal thoughts:*
  • Self-Harming behaviour:*

  • Would you like David Hudson Counseling to share information with or receive information from another provider?

  • David Hudson Counseling

    3321 Candelaria Rd NE • –Suite 159 • Albuquerque, NM 87107 • 505.514.9361

  • Authorization for the Release of Confidential Information Form

  • I would like to:

  • Organization/Individual information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Information to be released:
  • OR indicate the specific categories to be released:
  • Purpose for Disclosure:

  • I understand that:

    My health information is protected by federal regulation (Alcohol & Drug Abuse Patient Records, 42 CFR Part 2; and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization.

    ▪ I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. This authorization will expire in one year from the date I sign or unless I request an earlier expiration in writing.

    ▪ For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party) (45 CFR & 164.508 (b)(4)(III))

    ▪ Communications resulting from this authorization will reveal that I receive services at David Hudson Counseling.

    ▪ Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information from alcohol & drug abuse patient records. However, HIPAA requires David Hudson Counseling to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA.

    ▪ This authorization may be used by David Hudson Counseling owned or managed programs upon transfer of my care to them.

  • Date
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    2 digit month, 2 digit day, 4 digit year
  • Date
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    2 digit month, 2 digit day, 4 digit year

  • Your rights as a client

  • As a client, you have the right:

    • To be treated with respect and dignity

    • To have your privacy protected

    • To help develop a plan of care with services to meet your needs

    • To participate in decisions regarding your mental health care

    • To receive services in a barrier-free location (accessible)

    • To request information about names, location, phones, and languages for local agencies

    • To receive the amount and duration of services you need

    • To be free from use of seclusion or restraints

    • To receive age and culturally appropriate services

    • To understand available treatment options and alternatives

    • To refuse any proposed treatment

    • To receive care that does not discriminate against you (e.g. age, race, type of illness)

    • To be free of any sexual exploitation or harassment

    • To have a second opinion from a mental health professional

    • To file a grievance with your agency

    • To choose a mental health care provider or choose one for your child who is under 13 years of age

    • To change mental health care providers if you feel that you are not connecting well with your counselor

    • Be free from retaliation

  • Your responsibilities as a client

  • As a client, you have the responsibility:

    • To take part in decisions about your health care, including the right to refuse treatment, except as provided by law.

    • To be involved in creating your treatment plan and goals, and tell your provider if you do not understand or do not agree with the plan.

    • To give your treatment provider all of the information needed so that all of you can make the best decisions about your care.

    • To arrive on time for appointments.

    • To call ahead of time and set up another appointment If you cannot make an appointment,

    • To treat staff and other consumers with the same courtesy you expect.

  • Crisis Intervention Plan

  • In the event that I am not mentally capable or able to care for myself, I wish to have the following people contacted:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • If I need to have more intensive services to help me, I prefer to use or go to:

  • Please do not contact the following people as they are not supportive or beneficial for me in a time of crisis:

  • I understand that David Hudson Counseling is an outpatient, voluntary, mental health counseling agency. I understand that they are not in a position to provide any triage services, medications or force me to do anything that I am unwilling to do. As such, I also understand that if I am considered to be at risk of harming myself or others, or I am not mentally or physically stable to care for myself, they will immediately call 911 and my first point of contact listed above. If possible, they will advise emergency services of my chosen hospital so that I can receive additional care and treatment.

  • Date*
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    2 digit month, 2 digit day, 4 digit year

  • Policies/Informed Consent

  • Confidentiality:  All sessions with a counselor are confidential.   A counselor is legally required to break confidentiality regarding what you have communicated only if you threaten to do harm to yourself or another individual and the counselor reasonably believes that you may act on that threat. In such situations, the counselor ordinarily arranges for you to be evaluated by a psychiatrist or psychologist in a hospital setting. It also may be necessary to contact family members or others who can help to provide for your safety. In cases of threats or actual violence toward another, the counselor is legally obliged to take protective actions, which may include notifying the potential victim, campus security and/or the police in the potential victim's community. Counselors also must break confidentiality by filing a report with the appropriate state agency if they become aware and believe that a minor (under age 18), disabled, or elderly person is suffering abuse.

     

    Your counselor may consult and seek supervision with another professional about his/her assessment and/or treatment. Efforts are made to avoid revealing your identity in all such consultations and supervisory sessions. All of the consultants are also legally bound to maintain confidentiality.

     

    If there is a question of cognitive impairment, it is important that you appoint a "Durable Power of Attorney" for assistance with the consent process. Essentially, this means that the family will choose another person, usually a close family member, to participate in the informed consent process and act as a surrogate or proxy if and when you need assistance. However, the final decision to enter or leave the program always belongs to the individual patient. And confidentiality will be maintained.

     

    Length of Sessions:  Sessions usually last 45-50 minutes.  Longer sessions can be arranged.

     

    Payment Policy:  If insurance is involved, we will bill your insurance company. However, co-pays or any other additional payments due are to be paid at the time of service.  Returned checks require payment for the returned check and all future payments by cash or credit card plus any bank fees.

     

    Cancellation Policy:  There is a $50 charge for appointments missed or canceled with less than 24 business hour notice. 

     

    Emergencies:  In case of a crisis call (505) 514-9361 and if no one answers, please call 911.  If you leave a message, the on-call counselor will return your call as soon as possible.  If there is an immediate risk of danger to anyone, call 911 first and then call us.  Please follow the guidelines presented to you during orientation to determine if the situation constitutes an emergency/crisis.

     

    I consent to treatment and accept the conditions of the policies above.

  • Date*
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    2 digit month, 2 digit day, 4 digit year
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