CHILD/ADOLESCENT INTAKE FORM

Hello! Just a quick note to let you know how excited We are to have you as a new client, and to thank you for allowing Mindful Steps to work with you. Before your appointment, please read the following polices and complete. It is important this is completed before your first session. We are happy to discuss the details with you and answer any questions you may have before your first session. Therapy is a teamwork effort; at Mindful Steps, we believe that by working together we can reach the destination that you desire. We look forward to meeting with you.

Treatment is voluntary. You may ask questions before deciding whether to proceed, and no outcome is guaranteed. By continuing, you confirm you understand and consent to participate in treatment under these conditions.

Your communications and records are confidential except for authorized releases, disclosures permitted or required by law, mandated abuse or neglect reporting, serious safety concerns, and lawful court requirements. We do not promise absolute confidentiality.

Participation in therapy can result in a number of benefits to you, including and not limited to improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Here at Mindful Steps, we intend on attending to your individual needs. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your involvement, honesty and openness in order to change your thoughts, feelings, and/or behavior. We will ask you for your feedback and views on therapy, its progress, and other aspects of therapy and will expect you to respond openly and honestly. Sometimes more than one approach to therapy can be helpful in dealing with certain situations. During the initial evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, anxiety, depression, insomnia, etc. We may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations which can cause you to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance abuse, schooling, housing or relationships. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

You may stop treatment or withdraw consent at any time. The therapist may end treatment when clinically appropriate, when the service is outside the therapist's scope, or when continued care cannot reasonably be provided, with notice and transition or referral assistance as appropriate rather than abrupt abandonment.

Your sessions with your Therapist may end due to a decision on your part, your Therapist part, or both. In psycho-therapeutic treatment, the relationship is an important part of the process. Therefore, it is most effective when we can plan for at least one session if not several to do the closure. As mentioned, after the consultation, we will assess if we can help you. We do not accept clients whom, are beyond our scope of practice. In such a case, you will be provided with a number of referrals that may be of help to you. You have the right at any time to consult another professional for his/her opinion.

1. The client may ask questions on what to expect during and end result of the therapy.
2. The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist.
3. The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.
4. The therapist has the right to dismiss the client from the course of therapy.
5. The client has the right to review his or her records from the therapist.
6. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client.

7. The client can raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client.

Mindful Steps and our Therapist have various social media accounts (ie: Facebook, Instagram, LinkedIn, Twitter, TikTok,etc.) allowing us to share practice information, news and event updates with other social media users. This document outlines our practice's policy related to use of Social Media. Please read it to understand how we conduct ourselves on the social sites as mental health professionals and how you can expect us to respond to various interactions that may occur between clients and clinicians on the Internet. This policy is not meant to keep you from sharing that you are in therapy at Mindful Steps or with a particular therapist wherever and with whomever you like. Confidentiality means that we cannot tell people that you are a client. You are encouraged to take your own privacy as seriously as we take our commitment of confidentiality to you.

Friending
Therapists are not permitted to accept "friend" requests from current or former clients on their personal social networking sites (Facebook, Twitter, LinkedIn, etc.). Adding clients as "friends" on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you meet with your therapist.

Liking/Following
You are welcome to 'like" or "follow" our social media feeds and read or share articles we post; however, because social media sites are public spaces, anyone who can see our social media pages can see your post or comment. In addition, when you post, comment, or "like" a page, it will be published on your page as well. Our primary concern is your privacy. You are welcome to use your own discretion in choosing whether to follow our practice. In order to maintain ethical boundaries, therapists are not permitted to follow you back. We believe casual viewing of clients' online content outside of the therapy hour can create confusion in regard to whether it's being done as a part of your treatment or to satisfy curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on the therapeutic relationship. If there are things from your online life that you wish to share with your therapist, please bring them into the sessions where those things can be viewed and explored with your counselor, during the therapy session.

Texting/ Messaging
Please do not use SMS (mobile phone text messaging), wall posting, @ replies, messaging on Social Networking sites in order to contact your therapist. Engaging with your therapist in this way could compromise your confidentiality and the therapist may not even receive your message. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.

Use of Search Engines
It is NOT a regular part of our practice to search for clients on Google or Facebook or other search engines. Due to the fact that therapists are mandated reporters, extremely rare exceptions may be made during times of crisis. If a therapist has reason to suspect you are in danger and you have not been in touch with your therapist via usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if your therapist resorts to such means, the information will be fully documented and discussed with you during your next session.

Insurance verification is not a guarantee of payment. You are responsible for applicable copayments, coinsurance, deductibles, and session charges not covered by insurance, including when coverage lapses or terminates, only to the extent permitted by law and the applicable insurance/provider agreement.

Please notify Mindful Steps promptly of any insurance changes. Any self-pay charges will be explained before services are provided.

Additional fees and chargeable services, including any denied-claim handling or nonpayment authorization, are subject to the same insurance and responsibility limitations described above and are only applied to the extent permitted by law.

I have read and understood the above information, and any questions that I had have been answered. I agree with the above consent form, and freely consent to receive psychological services.

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By signing using any device, means, or action, I consent to the legally binding terms and conditions of this document.

I hereby authorize Alexandra Mayes, MS., Pre-Licensed Professional Counselor to disclose to and exchange the following information with:

I have read and understood the above information, and any questions that I had have been answered. I agree with the above consent form, and freely consent to receive psychological services.

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By signing using any device, means, or action, I consent to the legally binding terms and conditions of this document.

Please use your insurance card to fill out the information below

I Authorize Mindful Steps to charge my card for the balance of fees denied by my insurance company, or not paid by my insurance company within 90 days of date of service. If I have questions about these charges, I agree to contact Alexandra Mayes, LPC-MHSP.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information ("PHI") that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client's personal health information without the client's written authorization, to carry out the health care provider's own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

1. Psychotherapy Notes. I do keep "psychotherapy notes" as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.

b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

Telemental health is live two - way audio and video electronic communications that allows therapists and clients to meet outside of a physical office setting.

I understand that telemental health services are completely voluntary and that I can withdraw this consent at any time.

I understand that none of the telemental health sessions will be recorded or photographed.

I agree not to make or allow audio or video recordings of any portion of the sessions.

I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental health, and that no information obtained in the use of telemental health that identifies me will be disclosed to other entities without my consent.

I understand that telemental health is performed over a secure communication system that is almost impossible for anyone else to access. I understand that any internet based communication is not 100 % guaranteed to be secure.

I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal information by bypassing the security measures of the communication system.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.

I understand that I or my therapist may discontinue the telemental sessions at any time if it is felt that the video technology is not adequate for the situation.

I understand that if there is an emergency during a telemental health session, then my therapist may call emergency services and/ or my emergency contact.

I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and that all office policies and procedures apply to telemental health services.

I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re - contact.

I understand a "no show" or late fee will be charged if I miss an appointment or do not cancel within 24 hours of scheduled appointment. I understand credit card or other form of payment will be established before the first session.

I understand my therapist will advise me about what telemental health platform to use and she will establish a video conference session.

Please review the consent information below carefully. Your final signature applies to the displayed treatment consent, termination rights, confidentiality, financial responsibility including insurance denial or lapse, and telehealth terms.