Sheila B. Maitland, LPCS

(704) 560 4388

Client Information

Date ______

Name ______Age ______DOB______

Address______

City______State______Zip______

Cell # ______OK to Call/Leave Message ______

Work #______OK to Call/Leave Message ______

Home #______OK to Call/Leave Message ______

Email Address ______

This email address is for session reminders and scheduling.

Occupation______Employer______Years there_____

Spouse’s Occupation______Employer______Years there_____

Single, Partner, or Married? ______How Long? ______Status of your relationship? ______

Referred by ______

Have you ever been in counseling before? ______When? ______

Name of Counselor/Facility Dates Reason treated

______

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Was counseling helpful? Why or why not? ______

Emergency Contact ______Phone (Cell) ______Relationship to you______

List everyone living in your house and their age ______

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Attend Church ______If so, where?______

What made you decide to seek out counseling and come to this appointment?______

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What do you hope to achieve from counseling?______

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List any medication you are currently taking. Included length of time you’ve taken and dosage.______

______

Physician that prescribed medication______

List any past or present events that you feel would be helpful for me to know. (abuse, trauma, addiction, &/or illness)______

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Are you experiencing any of the following? (circle)

Depression Anxiety Loneliness Sleep irregularity Crying Spells Nervousness

Angry Outbursts Violent Behavior Change in Sex Drive

Loss of Energy Thoughts of Suicide Suspicious thoughts

Loss of Appetite Increased Fears Phobias or Hallucinations Increased Medication Difficulty with Relationships Difficulty at work

Increased use of Alcohol Medicating with Food Medicating with Money

Please briefly write about the issues that you circled.______

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Anything else that would be helpful for me to know. ______

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Signature Date

Print and bring completed form to your first session

Sheila Buck Maitland, LPCS; I received my Masters of Education and Education Specialist Degree in Guidance and Counseling from the State University of West Georgia in 1993 and 1994 respectively. Currently, I hold a Professional License in North Carolina. I have been working with addiction and codependency for more than 20 years and provide individual, couples and group therapy in my private practice. My theoretical orientation is psychodynamic and I utilize experiential techniques or action therapies when working with clients.

·My goal is to always treat you competently, ethically and respectfully.

·When referred to me for group therapy, the process will be supplemental to your existing individual therapy. This is not intended to replace your individual work.

·You may view your records. I encourage active participation in you therapy. I will provide you with a diagnosis, and if you decide to file a claim with your insurance, it will become a part of your permanent medical record.

·Our discussions are confidential. This means that except where noted below, I will not release information that identifies you to anyone without your written permission. In certain situations, I must reveal information about you to others even without your permission. These situations include:

A) If there is risk that you may harm yourself or others, I will share information necessary to keep you and others safe.

B.) I have to release to a court of law any information specifically described by a court order.

C.) I will tell the Department of Social Services about any reasonable suspicion I have that a minor or dependent is being abused or neglected.

·I request that you pay me at each session and that you file your insurance claims as necessary. My fee is $150 per hour for a 55 minute hour. Initial assessments last a minimum of 80 minutes and cost $225. If you cancel or postpone an appointment, 24 hours notice is necessary to prevent being charged for the missed appointment. These appointment times have been reserved especially for you.

·As a client and consumer, you have the right to register a complaint. Should you feel the need to do that, the complaint should be filed in writing to: The North Carolina Board of LPC; 893 US HWY West, Suite 202; Garner, NC 27529.

·Please indicate your understanding and acceptance to the stated information with your signature.

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Signature Date

Counseling Policies

Therapist/Client Contract

Client’s Rights and Responsibilities

These policy statements have been developed in order for there to be a clear understanding about what the therapeutic relationship is like between therapist and client. They are written in accordance with current legal and ethical standards. Please read the following and sign that you have a clear understanding. If there are any questions, let’s talk about them so that we can have a good, solid working relationship.

BENEFITS and RISKS of THERAPY Research has shown that therapy is beneficial for a wide variety of problems. The majority of people who receive counseling make significant improvements. However, it should be understood that some people do not report themselves as significantly improved at the end of treatment and a small percent report feeling worse after receiving treatment. Therefore as with any treatment, whether it is psychological or medical, therapy should only be entered with proper consideration. You always have the right to inquire and to choose treatment modalities.

CONFIDENTIALITY Therapist has an ethical and moral obligation to keep information revealed in session confidential. There are several exceptions to this rule. In an emergency when there is eminent danger to the client or another person, the counselor may breach the confidentiality, and North Carolina Law requires that suspected child, elder abuse, or domestic violence be reported to the Department of Human Services. Otherwise, information will only be released with written permission unless client is under the age of 18.

FEES and APPOINTMENTS Client sessions are a 55 minute hour unless otherwise scheduled. The charge for the therapy hour is $150. Scheduled phone sessions are also available to current clients. The charges are incurred in 15 minute blocks. The charge per each block is $40. Clients will receive a session reminder through email as well as an email invoice for session and/or phone charges. Payments are due by the end of the day of the session.

Clients will be billed a session fee for appointment not cancelled 24 hours in advance.

PHONE CALLS and EMAILS Most all communication is done through email since longer phone calls incur charges. Response to email and voice mail is usually done daily or within a 24 hour period. If there is an emergency, call 911 or go to the nearest emergency room.

I have read and agree to accept the above stated policies.

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Signature Date