Stacy Vollands MS, MS, LPC, LCDC
Counseling & Recovery
Professional Services Informed Consent
White Stone Building 26205 Oak Ridge Drive Suite 115 The Woodlands, TX 77380 832-598-5447Introduction
Thank you for choosing Stacy Vollands Counseling & Recovery. I have a Masters Degree in Professional Counseling and a Masters Degree in Educational Psychology. I am Licensed by the State of Texas as a Licensed Professional Counselor and a Licensed Chemical Dependency Counselor. I am so glad you are here and I look forward to working with you. This document will serve as an introduction to the counseling process and answer some of the questions that you may have. If you have other questions that are not addressed here, please feel free to ask.
Today’s appointment will take approximately 45-50 minutes. It will include discussion about counseling practices, limitations and risks as well as your needs and goals for counseling. This document informs you of your rights, our policies, as well as state and federal laws. If you have any other questions or concerns, please feel free to ask.
Payment Information and Insurance
There is a set fee for each session that is due at the end of your appointment. Please speak to your counselor to obtain a clear understanding of the fee. I am not accepting insurance at this time. Applications have been made to Aetna, Blue Cross/Blue Shield and Magellan. I will inform you if and when these applications are accepted. In the meantime, I accept cash, check, and credit cards (Mastercard, Visa, American Express and Discover). You are responsible for payment in full at the end of each session. Please be advised that payment of your sessions with check or credit card could provide sufficient information to financial institutions and their employees to identify you as a client.
Cancellations:
Please provide a 24-hour notice of cancellation of your appointment. The advanced notice is standard practice in the counseling profession. Failure to provide notice will result in a cancellation fee of the entire session fee. You will have access to the therapy portal where you can cancel or change an appointment in a timely manner.
______PLEASE INITIAL HERE THAT YOU HAVE READ AND UNDERSTAND THE 24HR CANCELLATION POLICY.
Emergency Contact
I do not provide crisis intervention or intensive crisis counseling. If you have a crisis after office hours, please call the crisis hotline at 713-468-5463, or go to your nearest emergency room.
Relationship
Your relationship with me is a professional and therapeutic relationship. In order to protect that relationship, it is important that I not have any other personal or business affiliations, including social media friendships as they can undermine the therapeutic agreement. Being “friends” on social media can compromise your confidentiality and privacy. It could also be confusing to the professional therapeutic relationship. I do have a business Facebook page where I post mental-
health tips and information, if you would like to follow me. Please be aware, however, that certain comments/likes may identify you as a client.
To protect your confidentiality, I will not approach you in any setting outside of the office. It would be appropriate for you to acknowledge and approach me if you would like. If you do, I will talk with you, but as your therapist, I will keep your information confidential in public and will not discuss issues that we discuss in the counseling office.
LITIGATION LIMITATION
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.) neither you nor your attorney’s, nor anyone else acting on your behalf will call Stacy Vollands, LPC, LCDC to testify in court or at any other proceeding. In addition, a disclosure of the psychotherapy notes will not be requested.
BEREAVEMENT NOTICE
In the unforeseen event that I should pass away, my records will be taken over by another Licensed Professional Counselor. Your files will be transferred to their practice during the interim, at which point you can decide if you will continue with counseling with them or choose another professional.
RISKS OF COUNSELING
Often growth cannot occur until you experience and confront issues that may bring about a wide range of emotions, including sorrow, sadness, anxiety or pain. The success of our work together will depend on the quality of the efforts on both of our parts and the realization that you are responsible for lifestyle choices/changes etc. that may result from counseling.
TERMINATION OF COUNSELING
Discussion and action toward counseling termination and/or referral will be made when: Your counseling goals have been achieved, you no longer want counseling or do not return for counseling, you are no longer benefitting from counseling or counseling wouldotherwise not be in your best interest. Please communicate your needs to me and we can discuss different options.
If you do not schedule an appointment for three consecutive months, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
Your signature below indicates you have read and understand this document and that you agree to its terms.
I, ______HAVE READ, UNDERSTAND, AND AGREE TO THE PRACTICE POLICIES CONTAINED HEREIN.
______
Signature of Client (Parent/Guardian if under 18)Date
Counselor Limits of Confidentiality
Your counselor recognizes that confidentiality is an important part of effective counseling. For counseling to work best, you must feel safe when you share your personal information with your counselor. Under most circumstances, all information about you, in written or verbal form, obtained in the counseling process (including your identity as a client) will be kept confidential. Information will not be disclosed to any outside persons or agency without your written permission except in certain situations, which include, but are not limited to:
* We believe you are in imminent danger of harming yourself or others.
* If you disclose abuse or neglect of children, the elderly, or a disabled person.
*We may need to disclose information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims, as well as, information needed for billing and collection purposes.
*When disclosure is relevant to any suit affecting the parent-child relationship, which includes divorce and child custody deliberations.
*In criminal court proceedings.
*In proceedings in which a claim is made concerning one’s emotional or mental condition.
*In legal or regulatory actions against a professional.
*To qualified personnel for certain kinds of audits or evaluations.
*Where otherwise legally required.
I agree to the above limits of confidentiality and understand their meanings and ramifications.
______
Signature of Client (Parent/Guardian if under 18)Date
COUNSELING INTAKE FORM
CLIENT INFORMATION
Confidential
Please provide the following information for your assessment and consultation.
Demographic Information
Name:______Date:______
Date of Birth: ______Age: ___ Place of Birth:______Gender___ Address______
City: ______State:______Zip Code: ______
Home Phone: ______May we leave a message? Yes No
Cell Phone: ______May we text message you?YesNo
Email Address: ______May we email you?YesNo
Emergency Contact: ______Contact Phone: ______
Highest Grade Completed/Degree:______Type of Degree:______
Employer:______Work Phone:______
Marital Status: Single Married Divorced Separated Remarried Widow(er)
Do you have children? YesNo
If so, please list names and ages:
______
______
Who lives in your home?
______
Current Concerns that have led you to counseling: ______
How long have these issues been going on? (History of the problem)
______
Referred by: ______
Have you ever seen a mental health professional before (social worker, counselor, psychologist, psychiatrist)? Yes No
If you have seen a mental health professional before briefly list the reasons for seeking help and when you received this help: ______
What are your goals for counseling? ______
______
______
PLEASE COMPLETE THIS SECTION FOR MINORS ONLY (17 YEARS OF AGE OR YOUNGER)
Parent/Legal Guardian: ______Relationship to Client: ______
Address: ______
City: ______State: ______Zip: ______
Phone: ______Alternate#: ______
Email address______Employer/School______
Please note: If divorce or a temporary order has precipitated custody arrangements, please provide a copy as soon as possible, particularly if one parent is sole conservator. If applicable, who is the sole conservator? ______
I give permission for my child to receive counseling/therapy services.
______
Signature of Parent/Legal Representative Date
(if client is under 18)
______
Are you currently taking any medication for mental health issues? YesNo
Please list medications: ______
Have you ever tried to take your own life? YesNo
If yes, when? ______
Have you ever been hospitalized for a mental health issue? Yes No
If yes, when and where? ______
Do you have any current diagnosis?
______
Are you currently having thoughts of taking your own life?YesNo
ALCOHOL AND DRUG INFORMATION
Do you drink alcohol?YesNoLast use? ______How often? ______
Do you use/abuse drugs?YesNo
If you do use drugs, which drugs? ______
Date/time of last use______How much do you use?______
How often? ______Where/With whom?______
Current withdrawal symptoms (i.e. shakes, convulsions, hallucinations, cravings)?
______
Are you in recovery from substance or alcohol abuse?YesNo
If so, how long have you been sober? ______
Please provide a brief description of any treatment or support you receive for maintaining sobriety. ______
Do you have any physical medical concerns?YesNo
If yes, please explain: ______
Do you currently take medications for these concerns?YesNo
If so, please list your medications:
______
What is your physician’s Name?
______
Would you like your physician to have information about your counseling sessions?
YesNo
(If yes, please ask your counselor for a Release of Information form)
Physical Health (Check all that apply)
☐Back Pain / ☐Dizziness / ☐Fatigue / ☐ Fainting☐Headaches / ☐Hearing Problems / ☐Blackouts / ☐ Muscle Spasms
☐Heart Palpitations / ☐ Shortness-of-breath / ☐Stomachaches / ☐ Tension
☐Tremors
☐ Weight Loss / ☐ Unable to relax
☐ Weight Gain / ☐Visual Disturbances
☐ Other: ______
Feelings (please check all that apply):
☐Angry / ☐ Argumentative / ☐Avoiding / ☐Anxious☐Bored / ☐Conflicted / ☐Crying Spells / ☐Depressed
☐ Distracted / ☐Fearful / ☐Frustrated / ☐Irritable
☐Impulsive / ☐Lonely / ☐Racing Thoughts / ☐Rejection
☐Restless / ☐Talkative / ☐Withdrawn / ☐Worthlessness
Behavior (please check all that apply):
☐Aggressive / ☐Can’t keep a job / ☐Compulsions / ☐Concentration problems☐Crying / ☐Drink too much / ☐Impulsive / ☐Lack of motivation
☐Loss of Control / ☐Nervous Tics / ☐Phobic avoidance / ☐Procrastination
☐Sleeping Problems / ☐Smoking / ☐Suicidal Thoughts / ☐Temper outbursts
☐Take Drugs / ☐Take too many risks / ☐Cutting / ☐Withdrawal
☐Work too hard / ☐Overeating / ☐Not eating / ☐Binge/Purge
Do you have any family members who struggle/have struggled with any mental health issues (Check all that apply). Please also add which family member has struggled with this.
☐Alcohol /Drug abuse ______/ ☐Anxiety______/ ☐Bi-Polar
______/ ☐Depression
______
☐Obsessive Compulsive
______/ ☐Schizophrenia
______/ ☐Suicide
______/ ☐ Domestic Violence
______
☐ Relational Issues
______/ ☐ Temper
______/ ☐Abuse (Victim)
______/ ☐Other (please list) ______
Spiritual Assessment
Do you believe in God?YesNo
Do you associate yourself with any particular religion?YesNo
If yes, which one? ______
Do you attend church? YesNo
If so, what is the name of your church? ______
Would you like to talk about spiritual issues in therapy?YesNo
Would you like your therapist to pray for/with you?YesNo
Please list any additional requirements/desires in this area for your therapist: ______
Other Information
Have you ever been in the military?YesNo
Is there anything else you would like me to know about you?
______
HIPAA NOTICE OF PRIVACY PRACTICES
This Notice of Privacy Practices describes our policies related to how medical/mental health information about you may be used and disclosed. It also describes your rights to access and control your protected health information. Please review it carefully.
Effective Date: February 15, 2017
Use and disclosure of protected health information (PHI) for the purposes of providing treatment, collecting payment and conducting healthcare operations are necessary activities for quality care. Protected Health Information (PHI) is information about you including demographic information that may identify you and that relates to your past, present or future physical or mental health condition.
Journey with Hope Counseling and Recovery is committed to providing services designed to meet your needs. We are equally committed to respecting your privacy and protecting the information about you that we receive. We will only release information in accordance with state and federal laws and the ethics of the counseling profession.
State and federal laws allow us to use and disclose your health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the law. Other permitted and required uses and disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.
We may use or disclose your protected health information in the following situations without your authorization. Exceptions are listed in the Counselor Limits to Confidentiality form in this packet.
We may use or disclose your protected health information for the purposes of TREATMENT. This may include providing, managing or coordinating care and any related services. To do this, we may disclose clinical information about you to doctors, nurses, technicians, or other agency personnel who are involved in providing services to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Different counselors may also share information about you in order to coordinate services.
We may also use and disclose health information for the purposes of PAYMENT. For example, we may disclose information to verify insurance coverage or process claims and collect fees. It may also be necessary to provide information about past or planned treatment to your health plan to obtain authorization or payment for expected and completed services.
We may also use and disclose PHI for the purposes of HEALTH. We may use and disclose health information for: Review of treatment procedures, Review of business activities, Certification, Staff training and Compliance and licensing activities.
OTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT include: Mandated reporting, Emergencies, Criminal damage, Appointment scheduling, Treatment alternatives and for other purposes as required by law.
CLIENT RIGHTS: You have the right to request where we contact you. This can include home, work and cell phone contacts.
You have the right to release your medical records. You must give written authorization to release records to others. You have the right to revoke that release in writing at any time. Revocation is not valid to the extent that you have acted in reliance n previous authorizations.
You also have the right to inspect and copy your medical billing records. Your counselor may deny this request. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and protected health information that prohibits access to protected health information. Please note there are charges for copying, mailing or faxing your records.
You also have the right to add information or amend your medical records. You may request we amend your record. We may deny the request. If denied, you have the right to file a disagreement statement. If there is a disagreement, this statement will be filed in the record. Any amendment request must be in writing.
You also have the right to an accounting of disclosures for a six-year period beginning with date the counselor came in to compliance. Exceptions include: disclosure for treatment, payment or healthcare operations, disclosures pursuant to a signed release, disclosure made to client and disclosures for national security or law enforcement.
You have the right to request restrictions on uses and disclosures of your healthcare information. This must be in writing. Your therapist is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to obtain a paper copy of this notice from this office upon request.
You may complain to the U.S. Dept. of Health and Human Services if you believe your privacy rights have been violated. Please contact us first with your complaint. We will not retaliate against you for filing a complaint. If you have objections to this form, please contact Stacy Vollands, MS, LPC, LCDC at 832-598-5447.
We reserve the right to change the terms of this notice and will inform you by mail of any changes as you have the right to receive changes in policy. You then have the right to object or withdraw as provided in this notice. I have received and read a copy of this document.
______Signature of Client Parent/Legal Representative (if client is under 18) Date