Welcome to Sparrow Counseling, LLC
Therese Kilgore, MC, LPC
7165 E. University DR, Bldg. 13, Suite 149
Mesa, AZ 85207
602-435-9157, Fax: 480-264-3232
Important Information for your First Session
Directions:
My office is located off University DR between Power RD and Sossaman.The office complex, Baywood Square Professional Park, is across the street from the Arizona Game and Fish Dept. Look for Building 13 and enter through the main door. My business name is on the door -Sparrow Counseling, LLC. When you enter the building at the main entrance walk to the hallway and turn right. Take a seat in the waiting room. You will pass restrooms as you walk down the hall to the waiting room. There will not be a receptionist when you arrive, so just make yourself comfortable in the waiting area and I will come outat your scheduled appointment time.
Directions
Take the 202 and exit at University Dr. Turn West on University Dr. and drive 2.5 miles to Sun Valley Blvd. (on the west side of University). Turn south onto Sun Valley BLVD. Turn right into the business complex, Baywood Square Professional Park, on the west side. Look for Building 13 on your left (the #13 is in the upper right corner of the building). From the US 60 you can exit Power Rd. and drive north to University. Then turn east to Sun Valley Blvd.From the Red Mountain Freeway, you can exit at Power RD and drive south on Power Rd. to University Dr. Then turn east to Sun Valley Blvd.
Intake Paperwork:
Please bring the following packet to your first session. This packet is lengthy and has a lot of information. Thank you for taking the time to review it and fill it out before your first session. I will be happy to answer any questions you have when we meet. The intake packet includes:
- Information Sheet
- Informed Consent
- Payment Agreement
- Personal History Questionnaire
What to Expect:
The first session is a time for us to discuss how we might work together. We will be discussing the reason you are seeking counseling at this time and refining our goals for treatment. It may be helpful for you to write down some of your thoughts regarding therapy prior to your first session.
Therapy is unique and highly dependent on the relationship between therapist and client. It is essential for both the therapist and client to feel that their relationship is a good fit. If your goals for treatment are outside the scope of my skill set, referrals to other therapists can be made. Additionally, if you feel that I am not a good fit for you, you may request a list of referrals to other therapists.
I look forward to meeting you!
Information Sheet
Client Information:
Name: ______Date of Birth:______
Street Address: ______
City:______State:_____Zip:______Home Phone:______
Employed by:______Work Phone:______
Marital Status: Married Divorced Single WidowedCell Phone:______
Email Address:______
Emergency Contact: Name ______Phone:______
Circle your preferred contact number above. May we leave you messages at this phone number? Y N
Responsible Party Information (If Different Than Above):
Name: ______Date of Birth:______
Street Address: ______
City:______State:_____Zip:______Home Phone:______
Employed by:______Work Phone:______
Email Address:______Cell Phone:______
Circle your preferred contact number above. May we leave you messages at this phone number? Y N
Spouse Information:
Name: ______Date of Birth:______
Street Address: ______
City:______State:_____Zip:______Home Phone:______
Employed by:______Work Phone:______
Email Address:______Cell Phone:______
Children: (Name and Birth Date): ______
______
Referred by: ______
Previous counseling experience:______
What do you hope to gain from therapy?______
______
I appreciate your payment in full, at the time of service. In the event you will not be able to keep an appointment, you must notify my office 24 hours in advance. If I do not receive such advance notice, YOU WILL BE FINANCIALLY RESPONSIBLE FOR THE LATE CANCELLATION/MISSEDAPPOINTMENT FEE FOR THE SESSION YOU MISSED.
Signature:______Date:______
Informed Consent for Assessment and Treatment
Welcome to my counseling practice. I am committed to providing counseling services, including psychotherapy, toward your desired outcome. A counseling situation offers a unique relationship between the two of us. In order to assist you in understanding the responsibilities and expectations involved in the therapeutic counseling relationship, I ask that you read and sign the following informed consent. I would be happy to provide you with a copy of your signed consent at the close of your initial session.
Professional Disclosure: I am a professional counselor in an independent private counseling practice. I earned my Master’s degree in Professional Counseling and Certificate of Advanced Graduate Studies in Christian Counseling from Ottawa University in Phoenix, Arizona and a Graduate Diploma in Christian Counseling from Phoenix Seminary in Phoenix, Arizona. I am a Licensed Professional Counselor in the state of Arizona by the Arizona Board of Behavioral HealthExaminers.Primary services I provide are psychological assessment and counseling/psychotherapy. I have experience in a variety of settings including inpatient detox facilities, community mental health clinics, substance abuse intensive outpatient programs and residential treatment facilities. I have also worked with a wide range of clientele, including children, adolescents and adults. Treatment modalities I provide include: individual, couples, group and family therapy. I provide services for marriage and family conflict, depression, anxiety, grief, trauma, addictions and spiritual/religious concerns and a variety of other psychological issues. I reserve the right to refer clients to another therapist or appropriate resource at any time if their needs in therapy are not a good match for my skills or experience.
Financial: Payment is expected at the time the service is rendered unless other arrangements have been made. By signing this document, you are agreeing to pay for the services rendered and any additional expenses that may be accrued in collecting said fees. Currently, the fee for an initial assessment is $120 and the fee for ongoing50-minute sessions is $100. In addition to the basic session and intake fees, there may be other fees for additional services such as telephone counseling, books and materials, etc. There will be a $40.00 fee for checks that are returned as non-sufficient funds or non-payable. I reserve the right to change my fees with 30 days notice. You have the right to be informed of all fees that you are required to pay and my refund and collection policies. If it is necessary to refer this account to collections, the client agrees to pay all collection fees involved. Collection charges include reasonable attorney fees. Refer to the payment agreement for more specific information regarding fees and payments. Please discuss these with me if you have a concern. I reserve the right to stop treatment if payment for services is not received.
Insurance: Effective October 1, 2017 Sparrow Counseling will no longer accept new clients wanting to use their health insurance plan benefits. Effective January 1, 2018 Sparrow Counseling will no longer accept or bill any health insurance plans or companies. If you want to check on your “out of network” benefits, Sparrow Counseling can provide you with a “superbill” to submit to your insurance carrier for reimbursement. When calling your insurance carrier ask for “mental health outpatient benefits for out of network” to determine what they are.
Availability of services: My practice does not have the capability to respond immediately to counseling emergencies. True emergencies should be directed to the community emergency services (911) or to the local hotlines (Empact: 480-784-1500, Banner Help line: 602-254-4357, Magellan: 602-222-9444). Established clients with an urgent need to make contact may call me, but an immediate response is not guaranteed. A quick or immediate response in one situation does not constitute a commitment of rapid response in another situation. Repeated late cancellations or missed appointments will be billed at $60 and may result in termination of treatment. Please note that this office does NOT do courtesy reminder calls. Whether you receive a reminder call or not you are expected to be at your scheduled appointment.
Appointments: Regular attendance at your scheduled appointments is one of the keys to a successful outcome in counseling. I reserve 45-50 minutes for each counseling appointment with a client. Appointments cancelled at the last minute are very detrimental to my practice. Therefore, I ask that you notify me a minimum of one full business day (24 hours, Monday through Friday) prior to your appointment if you need to cancel. You will be financially responsible for appointments you fail to cancel in accordance with this policy. See Payment Agreement for details.
Appointment availability varies with the client load at the time. High demand appointment times are likely to be sporadic in their availability. I reserve the right to limit my commitments of high demand appointment times to any particular client in order to meet the needs of all my clients and balance my workload. There are sometimes misunderstandings regarding the length of sessions. Therapy sessions are 50 minutes in length, unless other arrangements have been made. Longer appointments are sometimes useful and can be scheduled if you let me know you would like to do this ahead of time. The extra time will be private pay at $25 per 15 minutes. Also, please note that I DO NOT do any phone or email counseling. I believe strongly that personal contact facilitates a greater depth of understanding and makes our time together more productive. However, I am aware that there may be times when limited phone contact is necessary for business matters. Any lengthy calls will be billed. I do use internet video counseling services in replace of in office sessions if the client resides too far away or due to physical limitations. These services are provided on a cash basis only.
Email/Social Media: Sparrow Counseling, LLC does have email that is to be used for BUSINESS COMMUNICATION ONLY. This email does not get accessed daily. Email is not an accepted form of communication with the therapist and will not be treated as such. I do not communicate with clients on any of my private social media platforms. If you friend request me or request to follow me, I will not accept. This is considered a dual relationship that I am ethically bound not to have with past or present clients. I cannot be in a professional and personal relationship of any kind with any past or present clients. All of my social media platforms are private for this reason.
Privacy, confidentiality, and records:Ordinarily, all communications and records created in the process of counseling are held in the strictest confidence. However, there are numerous exceptions to confidentiality defined in the state and federal statutes. The most common of these exceptions are when there is a real or potential life or death emergency, when the court issues a subpoena, or when child/elder abuse or neglect is suspected. It also needs to be noted that anytime a client invites someone into a session with them, they are agreeing to allow confidential information to be shared with that session participant as a result of being invited into the therapy room and participating in the client’s treatment.
I also participate in a process where selected cases are discussed with other professional colleagues to facilitate my continued professional growth and to get you the benefit of a variety of professional experts. While no identifying information is released in this peer consultation process, the dynamics of the problems and the people are discussed along with the treatment approaches and methods. There are also times that my professional colleagues are requested to do chart audits/reviews for my professional growth. In these cases, your file, in entirety, will be reviewed by this peer and myself. The files are always protected and never leave the office. If you are not comfortable with this process, please talk with me and I will note so in your file.
Your confidentiality is guarded well by me. This includes the fact that you are a client. If we encounter each other in the community, I may nod or smile, but I will not acknowledge you as anyone I know. I’m not trying to be rude, but instead attempting to maintain your confidentiality. I am always very open to you greeting me if you indeed feel comfortable doing that.
There are also numerous other circumstances when information may be released including when
disclosure is required by the Arizona Board of Behavioral Health Examiners, when a lawsuit is filed against me, to comply with worker compensation laws, to comply with the USA Patriot Act and to comply with other federal, state or local laws. The rules and laws regarding confidentiality, privacy, and records are complex. The HIPAA NOTICE OF PRIVACY PRACTICES, included in this packet of information, details the considerations regarding confidentiality, privacy and your records. This packet also contains information about your right to access your records and the details of the procedures to obtain them, should you choose to do so. Periodically, the HIPAA NOTICE OF PRIVACY PRACTICES may be revised. Any changes to these privacy practices will be posted in my office, but you will not receive an individual notification of the updates. It is imperative that you read and understand the limits of privacy and confidentiality before you start treatment.
______Initials / I have read the HIPAA NOTICE OF PRIVACY PRACTICES and have had my questions about privacy and confidentiality answered to my satisfaction. I understand that the HIPAA NOTICE OF PRIVACY PRACTICES is incorporated by reference into this agreement.
In the event of my death, retirement, or incapacity, the records for my clients that are actively receiving services (seen within the last month) will be given to one or more local behavioral health professionals to facilitate the continuation of treatment. In such a situation, you have the right to continue treatment with this professional, discontinue treatment or ask for a referral. Records for my inactive clients will be handled by a “records custodian”, which may be an individual or company. The custodian will be responsible for satisfying records requests and destroying records when the legal time frames for records retention are satisfied.
Litigation Considerations: If you become involved in the legal system (divorce, custody, civil litigation, criminal activity, etc.) you can expect that I willNOT make recommendations, testify, or otherwise get involved in your legal activities. It is an inherent conflict of interest for a treating professional to also offer evaluations or opinions in legal matters. If a client has these expectations, it can affect their willingness to disclose personal information vital to treatment. If you need an evaluation for a legal reason, I will make a referral to an outside, unbiased professional who can perform this service. In signing this agreement, you agree that you will not call me as a witness to testify or to expect recommendations or other involvement in your legal activities.
Purpose, limitations and risks of treatment: Counseling/therapy like most endeavors in the helping professions is not an exact science. While the ultimate purpose of counseling is to reduce your distress through a process of personal change, there are no guarantees that the treatment provided will be effective or useful. Moreover, the process of counseling usually involves working through tough personal issues that can result in some emotional or psychological pain for the client. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended.
Counseling/therapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, relationships or virtually any other aspect of your life. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. 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. In the case of marriage and family counseling, interpersonal conflict can increase as we discuss family issues. Of course, the potential for a divorce is always a risk in marital counseling.
Treatment process and rights: Your treatment process will begin with one or more sessions devoted to an initial intake and/or psychological assessment so that I can get a good understanding of the issues, your background and any other factors that may be relevant. When the initial intake and/or assessment process is complete, we will discuss ways to treat the problem(s) that have brought you into counseling and develop a treatment plan. You have the right and the obligation to participate in treatment decisions and in the development and periodic review and revision of your treatment plan. You also have the right to refuse any recommended treatment or to withdraw consent to treat and to be advised of the consequences or such refusal or withdrawal.
Our relationship: The client/counselor relationship is unique in that it is exclusively therapeutic. In other words, it is inappropriate for a client and a counselor to spend time together socially. The purpose of these boundaries is to ensure that you and I are clear in our roles for your treatment and that your confidentiality is maintained. If there is ever a time when you believe that you have been treated unfairly or disrespectfully, please talk with me about it. It is never my intention to cause this to happen to my clients, but sometimes misunderstandings can inadvertently result in hurt feelings. I want to address any issues that might get in the way of the therapy as soon as possible. This includes administrative or financial issues as well.
Consent for evaluation and treatment: Consent is hereby given for evaluation and treatment under the terms described in this consent document and the HIPAA NOTICE OF PRIVACY PRACTICES. It is agreed that either of us may discontinue the evaluation and treatment at any time and that you are free to accept or reject the treatment provided. In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardian of the child and that I authorize services for the child under the terms of this agreement. For couples or families, all parties need to sign this informed consent. Your signature(s) below indicates you have read, understand and agree with all of the statements listed above.