New Client Form (Aaron)

How did you hear about Integrity Counseling?
Briefly describe the issues/problems that led you to counseling today:
What goals would you like to achieve in counseling?

INTEGRITY COUNSELING, INC. POLICIES AND CONSENT TO TREATMENT

FINANCIAL POLICY

Full payment is due at time of service (unless prior arrangements have been made). Please feel free to ask if you have any questions about our financial policy. Understanding our financial policy is important to our relationship. Insurance is a contract between you and your insurance company. We will file your claim to your insurance company or provide you with the proper information needed for you to file a claim. You are responsible for the timely payment of your account. If you have provided us with a debit or credit card that we maintain on file, then we may automatically charge you for appointments, copayments or co-insurance rates, or appointments that are missed or cancelled with less than 24 hours notice. If you have provided us with your health insurance information, we will send information such as appointment dates, procedures (i.e., CPT codes), and diganoses to your insurance company unless you specifically instruct us not to do so. We will send information electronically, so please read the HIPPA notice.   Uncollected balances may be turned over for collection or reported to the State Attorney’s office.

CANCELLATION POLICY

Please help us to serve you and others better by keeping your scheduled appointments. If you need to cancel or reschedule, please give us as much notice as possible so we can offer that time to someone else. Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal counseling session. This will be billed to you or processed using the debit or credit card we have on file. We may require prepayment in order to schedule a subsequent appointment.

CONFIDENTIALITY

Federal and State laws protect your confidentiality (See 42 U.S.C. 290dd-3 and 290ee-3, 42 CFR, Part 2, and 45 CFR, Part 160 and subparts A and E of Part 164) for federal laws and Florida Statutes 394.4615, 397.501(7), 456.057(6), 491.0147).   Your counselor will not share information with any person outside of Integrity Counseling, Inc. without your written permission, except as required by law or as needed to file your insurance claim. Information obtained from minors is not generally shared with parents without permission. Federal and state law prohibits psychotherapists from disclosing information to parents about the treatment of their children who are minors if the treatment is related to substance use and/or the minor is experiencing an acute crisis. HIPPA (Health Insurance Portability and Accountability Act) laws allow you access to your file and protect the electronic transfer of information.


Exceptions to Confidentiality: Federal regulations do not protect from disclosure of information related to a client’s involvement in a crime against property or personnel. We are required under State law to report suspected abuse of a child, elderly person, or individual with a disability. We may share limited information in the event of a medical emergency or in the event of a specialized court order signed by a judge. Your counselor must breech confidentiality if you report a specific plan or intent to cause serious bodily harm to an identifiable person.

CONSENT TO TREATMENT

"Counseling" is defined by the 20/20 Task Force, a group of 31 organizations representing the counseling profession, as "a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals."

"Psychotherapy" is defined by the American Psychological Association as "communication between patients and therapists that is intended to help people:
- Find relief from emotional distress, as in becoming less anxious, fearful or depressed.
- Seek solutions to problems in their lives, such as dealing with disappointment, grief, family issues, and job or career dissatisfaction.
- Modify ways of thinking and acting that are preventing them from working productively and enjoying personal relationships.
Your signature below indicates:
1. You are voluntarily seeking outpatient counseling and/or psychotherapy at Integrity Counseling, Inc.
2. You understand that you have rights and responsibilities regarding your participation in treatment, including the right to discontinue therapy.
3. You understand that you are strongly encouraged to discuss your treatment plan and status in treatment with your counselor. Counselors will also discuss alternatives, procedures, qualifications, and drawbacks to therapy.
4. You acknowledge that you have read, understand, and agree to the terms of the financial and cancellation policies described above.
5. You acknowledge that you have read, understand, and agree to the terms of confidentiality described above.
6. You acknowledge that you have been provided a copy of HIPPA/Privacy Practices implemented here at Integrity Counseling.
7. You understand that individual counseling sessions are intended to be 45-to-52 minutes in length.
8. You understand that Integrity Counseling does not provide emergency/crisis services. In a true emergency, you should call 911. If you are in crisis or are experiencing suicidal thoughts, you may instead choose to call the National Suicide Prevention Hotline at 1-800-273-8255, text a crisis counselor by texting HOME to 741741, or participate in an online chat with a crisis counselor at https://suicidepreventionlifeline.org/chat/. These resources are available 24 hours a day, 7 days a week.
With my electronic signature, I acknowledge that I understand the above information and consent to treatment at Integrity Counseling, Inc.. Note: Use your mouse (if using a computer) or finger/stylus (if using a mobile device) to sign your name.

Clear
Signature of parent/guardian (if applicable)

Clear

PSYCHOSOCIAL HISTORY

Treatment History

Have you ever participated in counseling, psychotherapy, psychiatric/mental health treatment, or substance abuse treatment? If so, please complete the following information to the best of your ability:

	Date(s)	Provider	Purpose/Focus of Treatment	Outcome
1st Treatment Episode
2nd Treatment Episode
3rd Treatment Episode
4th Treatment Episode
5th Treatment Episode

Trauma History
Did you experience any physical, sexual, or emotional/psychological abuse or neglect during childhood or as an adult? If so, please describe:
Have you had any experiences you’d consider to be traumatic (e.g., threat of serious harm/injury, natural disaster, victim of a crime, traumatic losses/deaths, etc.)? If so, please describe:
Family Psychiatric History

Has anyone in your family ever been diagnosed or treated for a mental health disorder or for an alcohol- or drug-related problem? Has anyone had these problems but not been treated? If either apply, please indicate below:

	Family Member	Problem/Disorder	Describe Treatment (if any)
Family Member #1
Family Member #2
Family Member #3
Family Member #4
Family Member #5

Sustance Use History

Please enter the following information for any substances including alcohol, tobacco, and drugs that you currently use or have used in the past:

	Past Use? (Yes/No)	Current Use? (Yes/No)	How Often in Past Year? (frequency)	How Much Each Time? (quantity)
Alcohol
Amphetamines
Benzodiazepines (e.g., Xanax)
Caffeine
Cannabis/Marijuana
Club Drugs (e.g., XTC, GHB, Molly)
Cocaine
Heroin
Inhalants (e.g., whippets)
Nicotine/Tobacco
Other Opiates
Opiates
Synthetic Marijuana (e.g., K2, Spice)
Other

Do you have any problems or concerns with your use of any of these substances?

YesNoI don't know

Educational and Vocational History
What was school like for you growing up?
What is the highest level of education/highest grade you completed?
Did you go to a college, grad school, or vocational trade program?

YesNo
If yes, describe your education/training (e.g., completed or not, degree(s), major(s), certification(s), etc.)
Describe any educational goals you may have for the future:
Describe your employment history:
Are you working now?

YesNo
What is your profession/occupation?
What is your annual income?
Describe any vocational/occupational goals you may have for the future:

Legal History
Have you ever been arrested?

YesNo
If so, when and what charge(s)?
Have you ever been involved in a lawsuit?

YesNo
If yes, please describe:

Strengths and Weaknesses
What are your strengths?
What are your weaknesses?
Should be Empty:

	Name of Medication	Dosage	Prescribing Physician	Purpose of Medication
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10