The Psychotherapy Practice of Makea J. Sanders, M.Ed, LPC

Disclosure Statement

Thank you for considering my counseling services. In order to help you make an informed decision, I have prepared this statement for you to read. Please review this statement in its entirety and sign it in the space provided. If you have any questions or concerns, I would be pleased to discuss them with you.

Types of Counseling Provided: The types of counseling services I provide are generally directed toward children, adolescents, adults, and families. Issues such as self-esteem, behavioral difficulties in school and/or home, divorce or separation, anxiety, depression, bereavement, and difficulties in family communication are among the range of situations with which I typically work. I also provide counseling services to children ages 5-17. For Adults, I provide therapy in individual or couples format. Individual counseling is my most frequently used modality, with group counseling being provided or offered as warranted.

Qualifications of Therapist: Makea Sanders possess a Bachelor’s of Science in Psychology and Master’s of Education in Counseling. Furthermore, I am a Licensed Professional Counselor (LPC) and conduct psychotherapy in English. If a translator is needed, please inform me so I can arrange this as needed.

Methods of Counseling: My approach to counseling is interactive in style and based on the empathic response model, which emphasizes the importance of understanding and coming to terms with feelings. My philosophy of counseling is based on the belief that the client possesses the power to change, and that it is my role to help the client become aware of how to understand and utilize that power. I also employ techniques of cognitive-behavioral counseling, which empowers the client to challenge your internal thinking process to motivate positive change in your life. This is a philosophy of empowerment---it accepts the client as the driving force in change. I believe this approach brings about effective long-term results, for the reason that the client discovers how to utilize his/her own inner strengths and gifts rather than having to rely on someone else for solutions to life's difficult issues.

Scheduling and Procedures of Appointments: Appointments can be made by calling 817-631-0919. During the course of counseling, you and/or your child(ren) will meet with your therapist for 45 min sessions. Generally, clients attend counseling once per week. For parents/guardians of children please remain in the building during the child’s therapy session. It is required of all parents/guardians to escort the child to the bathroom if the need arises during the appointment time.

Payment and Fees: In return for a fee of $100 per session, I agree to provide counseling services for you. Payments are due at the time services are rendered. Payments can be made with cash, check or credit card. I will ask to keep a credit card on file for payments of all services. Checks returned for any reason will incur a A$25.00 return-check fee. Please note that I reserve the right to suspend services if there is an unpaid balance on your account.

Cancellation Policy: In the even you are unable to keep an appointment, please give at least a 24 hour notification by calling 817-631-0919. If a cancellation occurs without a 24 hour notice, or if you fail to keep your scheduled appointment time, a fee of $50 will be billed to you.

Emergency/Crisis: Please know that this practice is not a 24 hour crisis counseling service. Should you experience an emergency requiring immediate mental health attention, call 9-1-1 or go to the nearest emergency room for assistance. Non-emergency matters can be directed to the main phone number at 817-631-0919 where clients can leave a voicemail. If the voicemail is received after hours, you will be contacted on the following business day.

Termination: You are free to discontinue treatment at any time and agree to notify the counselor at least two weeks in advance so that effective planning for continued care can be implemented.

Court: It is in your best interest to know that conducting expert witness/testimonial service is not in my area of interest or expertise. I do not agree to serve as an expert witness or to provide testimonial services for you. You agree not to cause my services to be used in this way. If you are seeking counseling for court or court-related purposes or motivations, I will provide you with alternative and appropriate referral sources. Should you, your attorney, your spouse’s or ex-spouse’s attorney subpoena me or your client file as a factual case witness, or involve me in court-related proceedings, you agree to pay me a retainer fee of $1,200 (8 hours at $150.00 per hour) at the time a subpoena is served these charges and any additional fees will be billed and expected to be paid within 48 hours of the court appearance. You agree to $150.00 for every hour of my time involved, including, but not limited to: case preparation, testimony, deposition, phone/email/text with client and any third party, preparation and filling of any court-related document, and any wait time related to a court-related process. You agree to pay for costs incurred for travel and accommodations including mileage at $.40 per mile. If a subpoena is issued for me, it be turned over to an attorney. I will consult with an attorney as necessary at your expense. You agree to pay my attorney fees in the event a subpoena. If you have a suspicion that your case will be going to court or you will need a therapist testimony, please let me know before a counseling relationship is established. Please note: A 48 hour advance notice is required if a cancellation occurs related to a court process including dismissal of case. The $1,200 retainer fee is non-refundable unless I receive a 48 hour advance notice of cancellation.

Confidentiality and Records: All of our communications become part of your counseling record. Adult and minor client records are maintained and destroyed in compliance with Texas and Federal laws. I hold your confidentiality in the highest regard. Specific information pertaining to your case will not be released to anyone except upon your written consent to release confidential information for specific purposes i.e. billing, situations involving risk of harm (see below) or court orders related to a criminal case or investigation. There are certain limitations to confidentiality, some of which are required by law and others are required by the professional ethical code established by the Texas Board of Examiners of Professional Counselors. Please be aware of the following exceptions to privileged communications:

  1. Any evidence or reason to believe that a situation of a child, elderly, or disabled adult is or has been a victim of abuse or neglect. By law, this information must be reported to the Texas Department of Protective and Regulatory Services.
  2. Any probability of physical harm to yourself or others. Protection from physical injury takes precedence over confidentiality; therefore, if an individual intends to take harmful, dangerous, criminal action against self or another, and I believe they are I imminent danger, I may choose to report such action or intent to the authorities.
  3. If a third party billable service is paying or reimbursing for counseling services, it may be necessary to provide the billable party with counseling diagnoses, nature, treatment plan and goals, and our progress.
  4. If a client discloses that they have a disease commonly known to be both communicable and life threatening counselors may be justified in disclosing information to identifiable third parties, if they are known to be a demonstrable and high risk of contracting the disease.

Click here to enter text.Initials: Should you, or an entity through your signature, request a copy of you you’re your child’s record, please be aware that a $30.00 processing fee will be incurred. Records may only be released if you provide a formal written request and sign a “Authorization for Release of Professional Information” form and proved a copy of your driver’s license. Records will be available within 14 business days from the receipt of the written request. An overall counseling summary, in lieu of records, will be provided free of charge upon written request. If records are subpoenaed, this does not indicate an automatic release of records. I will notify you of any subpoena and you will have the right to seek the appropriate parties to have the subpoena squashed. In order to prove the best service for my clients, I reserve the right to schedule a consultation at the initial request of the release of records to discuss the risks and benefits of releasing any records.

Click here to enter text.Initials: If the client is a child and one parent requests the records, the co-parent will be notified of the request by the counselor.

I (we) do hereby give my (our) consent for counseling and/ or related services at this private practice. I (we) understand that all information pertaining to my (our) services shall remain completely confidential except in those cases where confidentiality is limited by the conditions stated above. These limits of confidentiality, as prescribed by Texas law, have been explained to me. Further understand that any release of information concerning my (our) services shall occur only with my (our) written consent, excluding the above stipulated exceptions.

By my signature below, I acknowledge that I (we) have read and that I (we) understood this document , ad that any questions I (we) had about this document were answered to my (our) satisfaction and that I (we) was furnished a copy of this document. By signing below, I agree to comply with all its terms and requirements, give consent for Makea J. Sanders, M.Ed, LPC to work with me (or my child), and understand my (our) financial obligations including the cancellation policy stated above.

By my signature below, I (we) agree to inform my therapist of my decision to terminate therapy prior to my last visit. If my therapist believes that I can receive more effective treatment elsewhere, I (we) will be given referrals. I (we) understand that I (we) may not attend a session under the influence of alcohol or drugs or if I am in possession of a dangerous weapon. I (we) that I (we) have the right to agree to, or refuse mental health services provided by Makea J. Sanders, M.Ed, LPC.

☐By checking this box and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature.

Client Name: Click here to enter text.

Electronic Signature of Client, Parent and/or Legal Guardian: Click here to enter text.

Date signed: Click here to enter a date.

ADULT INTAKE FORM

All information contained in this questionnaire is strictly confidential and will become part of your medical record.

Client Information
Full Name:
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Address:Click here to enter text. / City, State:Click here to enter text.Click here to enter text. / Zip Code:
Phone: / Is it okay to leave a message? ☐ Y ☐N
Email: Click here to enter text.
Preferred Method of Contact:Click here to enter text.
Emergency Contact Information
Name:Click here to enter text. / Relationship:Click here to enter text. / Phone:Click here to enter text.
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Family Information
Please list all individuals living in the home(Name, Age, Gender, Relationship)
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Work Information
Name of Employer: Click here to enter text.
Number of years: Click here to enter text. / Occupation:Click here to enter text.
Please describe your work satisfaction: Click here to enter text.
Medical Information
Primary Physician Name: Click here to enter text. / Primary Physician Phone:Click here to enter text.
Address:Click here to enter text. / City, State:Click here to enter text. / Zip Code:Click here to enter text.
Date of last physical exam: Click here to enter a date. / Current on all vaccines? ☐Y ☐ N
Any current medical concerns? (If you have indicated yes, please describe the concerns) ☐Y ☐ N
Do you have any chronic illness (if yes please describe) ☐Y ☐N
Are you being treated for any current illness (es)? ☐Y ☐N
Have you been hospitalized? (If yes, please provide the reason and length of stay)
☐Y ☐N
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Please list current medications:
(Name, dosage, prescribing physician)
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Have you received the following therapies? (If yes, please give name of therapist and dates)
Physical Therapy ☐Y ☐ N
Speech Therapy ☐Y ☐N
Occupational Therapy ☐Y ☐N
How many hours does you sleep? Click here to enter text. / Do yousleep walk? ☐Y ☐N
Do you sleep talk? ☐Y ☐N
Do you have trouble falling asleep or staying asleep? ☐Y ☐N
Do you experience nightmares or night terrors? ☐Y ☐ N
How is your appetite? ☐Excellent ☐ Good ☐Fair ☐ Poor
How much caffeine do you consume daily? Click here to enter text.
Mental Health Information
Have you participated in therapy before? ☐Y ☐N
If yes, where, how long and why services were discontinued
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What was the outcome of this therapy?
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Have you ever been given a mental health diagnosis? ☐Y ☐N
If yes, please explain
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Have you ever seen a psychiatrist? ☐Y ☐ N
If yes, where and how long?
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Do you currently take any psychotropic medication? ☐Y ☐N
(Name of medication, dosage, use and prescribing doctor)
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What are your strengths?
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What are your coping skills (what you do to feel better)
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What are your current concerns?
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What have you done previously to today’s visit to resolve these issues?
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What are some of the goals you wish to address or achieve in counseling?
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Have any of these occurred in the last year:
☐Divorce/ separation ☐Change of schools ☐Moved ☐Death in the family ☐Financial problems ☐Other:
Family Psychiatric History- please check if any family member has been diagnosed with the following:
☐ Schizophrenia
☐Bipolar
☐Anxiety
☐Depression
☐Tics/Tourette’s
☐Mental Retardation
☐Delinquency problems / ☐Emotional problems
☐ Drug abuse
☐ Alcohol abuse
☐ Hyperactivity
☐ Bedwetting
☐Learning problems
☐Other:
Emotional/ Behavioral Evaluation- please check any of the following that relate to yourself:
☐Affectionate
☐ Aggressive
☐ Alcohol/drug use
☐ Angry
☐ Anxiety
☐ Bedwetting
☐ Bizarre behavior
☐ Blinking/jerking
☐Bullies/threatens
☐Careless/reckless
☐ Chest pains
☐ Clumsy
☐Confident
☐ Cooperative / ☐ Defiant
☐ Depression
☐ Eating disorder
☐Easily Distracted
☐ Fearful
☐ Follows direction
☐ Frustrated easily
☐ Hallucinations
☐ Head banging
☐ Hopelessness
☐ Hurst animals
☐ Imaginary friends
☐ Impulsive
☐ Irritable / ☐ Learning problems ☐ Lies frequently
☐ Low self-esteem
☐ Moody
☐ Nightmares
☐ Panic attacks
☐ Phobias
☐ Poor appetite
☐ Sad
☐ Separation anxiety
☐Sets fires
☐ Shares
☐ Shy or timid / ☐ Sick often
☐ Sleeping problems
☐ Slow moving
☐ Social Anxiety
☐ Steals
☐ Stomach aches
☐ Suicidal ideation
☐ Talks back
☐ Teeth grinding
☐ Trouble with peers
☐ Weight gain
☐ Weight loss
☐ Withdrawn
☐ Worries
Are there any cultural and/or community issues that may have impacted you, your child or your family? (For example: exposure to racism, discrimination, bullying mass violence, English as a second language or being born in different country)
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Risk Assessment
Have you ever had any thoughts, attempts or experience with self-harm? ☐Y ☐ N
If yes, please provide details.
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Have you ever had any thoughts or attempts of suicide? ☐Y ☐ N
If yes, please provide details.
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Has a family member or close friend ever committed suicide? ☐Y ☐ N
If yes, who and when?
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Have you ever had any thoughts or attempts of harming some else? ☐Y ☐ N
If yes, please provide details.
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Are there any guns or weapons in your house? ☐Y ☐ N
If yes, please specify whose and what type.
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Abuse history- Please indicate if there is a personal or family history of the following:
☐ Emotional (please provide detail)
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☐ Verbal (please provide details)
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☐ Physical (please provide details)
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☐ Sexual(please provide details)
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Does your family have an open case with CPS? ☐Y ☐ N
If yes please explain.
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Insurance Information
If insurance is being used, a valid insurance card and a valid governmental picture i.d. must be provided prior to the initial intake session. The same on the insurance card must match the name on the i.d or proof of any name change must be provided.
☐ Yes, I will be using my insurance
☐ No, I will not be using insurance and agree to pay out of pocket
Name of person responsible for payment:Click here to enter text.
Name of insured:
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Insured’s employer:Click here to enter text. / Employer’s phone number: Click here to enter text.
Insurance Company: Click here to enter text.
Policy Number:Click here to enter text. / Group Number: Click here to enter text.
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Claims Address:Click here to enter text. / City, State:Click here to enter text. / Zip Code:Click here to enter text.
Behavioral Health Phone Number: Click here to enter text.
Financial Responsibility
___initial: All professional services rendered are charged to the patient or the responsible party provided above. And are due at the time of service, unless other arrangement have been made in advance with this business office.
Assignment of Benefits
I herby assign all mental health benefits to include medical benefits to which I am entitled. I hereby authorize and direct my insurance carriers, including Medicaid, private insurance and any other medical/health care plan to issue payment check(s) direct to Heart to Hear Counseling Services, LLC for mental health services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand I am responsible for any amount not covered by insurance.
☐By checking this box and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature.
Electronic signature of client or parent/guardian: Click here to enter text.
Date signed: Click here to enter a date.

Makea J. Sanders, M.Ed, LPC