Kind Mind Counseling

Kind Mind Counseling

2602 1st Ave. Hibbing, MN 55746

Marmie Jotter—Direct: (218) 263-5949 Fax (218) 263-5949

Client Intake and Billing Information

Please fill out this form and email it to (Please note: Information you provide here is protected as confidential information.)

Name: Last , First Middle Date: Month/Day/Year

Name and Phone Number of Parent(s)/Guardian(s) (if under 18 years):

1. Name: First Last

Phone Number: ( ) - -

2. Name: First Last

Phone Number: ( ) - -

Birth Date: Month / Day /Year Age: Gender: Male Female

Marital Status:
Never Married Domestic Partnership Married
Separated Divorced Widowed

If married, my spouse’s name is: First Last We have been married for how long?

Please list any children/age:

1. Name, Age

2. Name, Age

3. Name, Age

4. Name, Age

5. Name, Age

6. Name, Age

House Address: House Number and Street City, State, and Zipcode

Primary Phone Number: ( ) - - May we leave a message? Yes No

Secondary Phone Number:( ) - - May we leave a message? Yes No

E-mail: May we email you? Yes No

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Employment: Employed Unemployed Student

Occupation:

Referred by (if any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
No
Yes, previous therapist/practitioner:

What method of e-therapy service are you interested in? Check all that apply.

E-mail Video Conference Call (Skype or Google Hangouts) Phone Call

Are you currently taking any prescription medication(s)?
Yes
No
If so, please list:

1.

2.

3.

4.

5.

Have you ever been prescribed psychiatric medication(s)?
Yes
No
If so, please list and provide dates:

1. Date

2. Date

3. Date

4. Date

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your current physical health? (please check)
Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing:

2. How would you rate your current sleeping habits? (please check)

Poor (2hrs or less) Unsatisfactory (3-4hrs) Satisfactory (5hrs) Good (6-7hrs) Very good (8+ hours)

Please list any specific sleep problems you are currently experiencing:

3. Please list any difficulties you experience with your appetite or eating patterns:

4. Are you currently experiencing any chronic pain?

No Yes If yes, please describe:

8. Do you drink alcohol more than once a week? No Yes
9. How often do you engage in recreational drug use?
Daily Weekly Monthly Infrequently Never

10. Are you currently in a romantic relationship? No Yes

If yes, for how long?
On a scale of 1-10, how would you rate your relationship? Select...12345678910
11. What significant life changes or stressful events have you experienced recently:

12. What do you consider to be some of your strengths?

13. What do you consider to be some of your weaknesses?

Please describe your main complaint or problem as specifically as you can:

How long have you experienced this problem?

Check all words/phrases that describe what you are experiencing.

[PHQ-9]

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Check the number that best fits you:

[0 = Not at all] [1 = Several Days] [2 = More than half the days] [3 = Nearly every day]

1. Little interest or pleasure in doing things…………………..…..…… 0 1 2 3
2. Feeling down, depressed, or hopeless…………………………..….…. 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much……..… 0 1 2 3
4. Feeling tired or having little energy………………………………..…... 0 1 2 3
5. Poor appetite or overeating…………………………………………..……. 0 1 2 3
6. Feeling bad about yourself -- or that you are

a failure or let yourself/your family down……………………..……. 0 1 2 3

1. Trouble concentrating on things, such as

reading or watching television……………………………………..…….. 0 1 2 3

1. Moving or speaking so slowly that other people

could have noticed? Or the opposite – been so

fidgety/restless that you have been moving a lot…………..…..... 0 1 2 3

1. Thoughts that you would be better off dead or

thoughts of hurting yourself in some other way…………..………. 0 1 2 3

[GAD-7]

Check the number that best fits you:

[0 = Not at all] [1 = Several Days] [2 = More than half the days] [3 = Nearly every day]

1. Feeling nervous, anxious, or on edge…………………………………….….. 0 1 2 3
2. Not able to stop worrying or control worrying…………….……………. 0 1 2 3
3. Worrying too much about different things………………………………... 0 1 2 3
4. Trouble relaxing……………………………………………………………………… 0 1 2 3
5. Being so restless that it is hard to sit still………………………………….. 0 1 2 3
6. Becoming easily annoyed or irritable……………………………………….. 0 1 2 3
7. Feeling afraid as if something awful might happen……………………. 0 1 2 3

If you checked any of these problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Check appropriate box below:

Not difficult at all Somewhat difficult Very difficult Extremely difficult

INTEGRATIVE HEALTH QUESTIONNAIRE

1. What’s getting in the way of you being happy/content?

1. Is your mind in a healthy place?

Yes

No, this is why:

1. Tell me about your romance life…

1. Are you authentic in your sex life?
2. Yes
3. No, this is why:
4. How are you finding meaning in your work life?

1. How are you connected to Source/Higher Power/ God?

1. Are you living out your life’s purpose?

1. How are you expressing yourself creatively?

1. If your body/symptom had a message for you, what would it be?

1. What does your mind/body need to heal?

1. Is there a loss in your life that you have not moved past?

ELECTRONIC THERAPY NOTICE & AGREEMENT

Kind Mind Counseling Center offers online counseling services for clients who are unable to receive direct, in-office services or who believe online counseling would be more helpful in their situation. However, there may be issues that would best be addressed during an in-office session. If I feel that there is a need for more in-depth counseling, I will refer you to my in-office practice or to other appropriate resources.

Electronic therapy (E-Therapy) is NOT suitable for clients who present to be suicidal, homicidal, or suffering from a major psychotic disorder, such as Major Depressive Disorder, Schizophrenia, and/or Borderline Personality Disorder. Our online therapy service will only accept minors who have parental consent for treatment. Kind Mind Counseling Center has the right to refuse online counseling services depending on the client's eligibility.

By choosing to participate in online counseling services, you (as the client) understand that e-therapy is different from in-office therapy. Various methods will be used to accommodate your needs and goals in therapy. The methods used and the results may differ from traditional in-office therapy.

I follow the laws and professional regulations of the State of Minnesota (USA) and the psychotherapy treatment will be considered to take place in the state of Minnesota (USA). I will only take clients who reside in the state of Minnesota.

COUNSELING SESSIONS

Phone and video conference calls will last for approximately 30-50 minutes per session. Video conference calls will be made via Skype or Google Hangouts. Please use this link to download Skype on your computer, mobile phone, or tablet: Our username for Skype is: msmarmie

If you have a Google account, please use this link to download Google Hangouts (through Google Plus): There is also a Google Hangouts App available for your Smartphone. You can connect with us on Google Hangouts through the email address . To connect through video with Kind Mind Center on Google Hangouts, please use this link:

The phone number used for phone sessions is (218) 263-5949, unless otherwise stated by therapist. Please allow the therapist to call you at your scheduled appointment time. Our phone sessions will last 30-50 minutes.

Email therapy sessions will be charged by the number of responses from the therapist. The email used for therapy will be . If you are interested in a more secure, encrypted email format, please consider signing up for your own free account at Safe-mail.net and email me at instead of my Gmail account. If you choose to email me at my regular email account, I will reply/send my response to you at your regular email address.

Email therapy and phone sessions do NOT include appointment scheduling or discussion about counseling services. A therapist will inform the client beforehand if payment will be necessary, if service is considered e-therapy.

The client is responsible to set aside time for scheduled sessions. We ask that you attend all scheduled sessions and notify Kind Mind Counseling Center at least 24 hours in advance of cancellation. Because sessions are paid for when scheduled, any missed e-therapy sessions will be charged the full fee amount, unless an exception is made by the therapist.

FEE

Kind Mind Counseling Center charges $125 per video conference session and $100 per phone session. Email therapy sessions will cost $75 for up to 3 responses from the therapist. These sessions will be paid for at the scheduling of the upcoming session. The client will use PayPal prior to the session to make payments for e-therapy. You can pay for your session using a debit or credit card on our webpage at kindmindcenter.com under the “online therapy” tab. Insurance typically does not cover e-therapy sessions at this time.

CONFIDENTIALITY AND SECURITY

My current email and text message formats are not encrypted. Therefore this method does not ensure online counseling/communication confidentiality because there exists a potential that emails can be intercepted much as office visits can be overheard outside the door or postcards can be read in transit. However, please know that I do take precautions with your best interest in mind. No person besides Marmie Jotter LICSW uses my iPhone or office computer. Both technological devices are password protected as a safety precaution in the event they were lost or stolen.

E-Therapy is not regulated by the Board of Social Work, but confidentiality is. Therefore, please not that this email address is not encrypted. However, you can be assured that your emails to this address are kept private, and are only read on technology systems that are password protected and viewed by Marmie Jotter LICSW alone.

Kind Mind Counseling Center may use or disclose your health information when required by law to do so.

ABUSE/ NEGLECT/ IMMINENT DANGER

Kind Mind Counseling Center is required, as a “mandated reporter”, to disclose your health information to appropriate authorities if there is reason to believe that you are an imminent danger to yourself, are a possible victim or abuse, neglect or domestic violent act(s) or a possible victim of other crimes. Such disclosure of your health information will be to the extent necessary to avert a serious threat to your health and safety of the health and safety of others.

DUTY TO WARN

Minn. Stat. §148.975: The duty to predict, warn of, or take reasonable precautions to provide protection from, violent behavior arises only when a client or other person has communicated to the licensee a specific, serious threat of physical violence against a specific, clearly identified or identifiable potential victim. If a duty to warn arises, the duty is discharged by the licensee if reasonable efforts are made which includes: communicating the serious, specific threat to the potential victim and if unable to make contact with the potential victim, communicating the serious, specific threat to the law enforcement agency closest to the potential victim or the client. Immunity from liability provision for disclosure.

NATIONAL SECURITY

Kind Mind Counseling Center may disclose to military authorities the health information of Armed forces Personnel under certain circumstances. Kind Mind Counseling Center may disclose to authorize federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. Kind Mind Counseling Center may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient as needed.

By printing your name below, this is your signature verification that you have read and understand the Electronic Therapy Notice & Agreement Form

Sign by Typing Full Name Here Date

Signature of Guardian or Personal Representative Date

HIPAA CONSENT FORM

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

• Obtain payments from third-party payers.

• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by Kind Mind Counseling Center of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Kind Mind Counseling Center has the right to change its Notice of Privacy Practices prior to signing the consent. I understand that Kind Mind Counseling Center has the right to change its Notice of Privacy Practices from time to time and that I may contact Kind Mind Counseling Center at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that Kind Mind Counseling Center restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that Kind Mind Counseling Center is not required to agree to my request restrictions, but if Kind Mind Counseling Center does agree to my request restrictions then Kind Mind Counseling Center are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that Kind Mind Counseling Center has taken action relying on this consent.

I understand by signing this form, I am making an informed consent to mental health treatment at Kind Mind Counseling Center.

Sign by Typing Full Name Here Date

Signature of Guardian or Personal Representative Date

To pay using PayPal or Debit/Credit Card, please use this link:

Please save this form and attach it to an email. Send to .

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