Intake Forms New Client IntakeInformed ConsentNotice of Privacy Practices - HIPAAInformed Consent For Online TherapyRelease of Information 01. New Client Questionnaire Contact Information*CHRISTY MELLEN, MEd, LPC Comperio Counseling PLLC 409.899.4600 firstname.lastname@example.orgName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth*Gender*Sexual Orientation:*Race/Ethnicity*Religion*Referred by*May I acknowledge referral*YesNoPhone*May I leave a message for you at this number?*YesNoEmail Okay to email you?*YesNoPreferred forms of communication*TextPhoneEmailEmergency contact (name, number, relationship):*Marital Status*Years in Relationship*Current Partner/Spouse’s name:*Age*Occupation*Current Physician:*Phone*Last Exam*Please list you have any medical diagnoses or concerns*Please List Current Medications with Dose & Purpose*Current Mental Health Providers-Please List Name, Contact Info., Dates of Treatment, Purpose of Treatment*Previous Mental Health Providers-Please List Name, Contact Info., Dates of Treatment, Purpose of Treatment*Please list three things that are important to you in your life:*Bellow you will find a list of common challenges people face. Please check any that apply to you at present.Anxiety Generalized Anxiety Obsessive thinking Specific fears/phobias Compulsive behaviors Panic attacks Social Anxiety Mood Sadness or Depression Mania Thoughts of suicide Anger or Irritability Loss of energy Mood Swings Loss of pleasure in life Emotionally overwhelmed Frequent crying Behaviors Self-harm behavior (cutting/burning/scratching self) Problems with eating Body-focused repetitive behaviors (skin picking, hair pulling, nail biting, etc.) Sleep Problems falling asleep Problems sleeping through the night Trouble waking up Fatigue/tiredness during the day Nightmares Cognitive Problems with attention or concentration Memory Problems Racing thoughts Paranoia Identity Sexuality Career choices Self-esteem Personal values Sense of self Body image concerns Cultural concerns Difficulties with Assertiveness Other History of abuse (emotional, physical, sexual) Problems with Alcohol or Drugs Grief or Loss Racism/ discrimination Traumatic experience Problems with job/school Financial problems Medical Problems Legal situation Other not listed above*If there is anything else you would like my therapist to know or ask about, please briefly describe here:*All of the above information that I have provided to Christy Mellen, MEd, LPC is true and correct. I understand that treatment plans and goal setting will be determined with this information and other information that I provide throughout our sessions.* I Understand Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms. 03. Treatment Contract Contact Information*CHRISTY MELLEN, MEd, LPC Comperio Counseling PLLC 409.899.4600 email@example.comName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PSYCHOTHERAPY TREATMENT CONTRACT*Welcome to my psychotherapy practice. This document contains important information about my professional services and business policies. Please read it carefully and note questions you have so we can discuss them at our next session. When you sign this document, it will represent an agreement between us and it will become part of your clinical record. PSYCHOLOGICAL SERVICES Psychotherapy varies depending on the goals you hope to achieve and the approach of the therapist. It is therefore important you take care in selecting a therapist that fits your style and goals. Our first few sessions will involve an evaluation of your current concerns, needs, history, and hopes for treatment. By the end of the evaluation, I will be able to offer you my clinical impressions and a recommended approach to treatment. During this time, we can decide if I am the best person to provide the services you need to meet your therapy goals. As therapy involves a commitment of time, money, and energy, it is important you feel comfortable working with me. If we agree to initiate psychotherapy together, both of us will determine how often we might meet in order for you to achieve the goals you hope to achieve. My approach to treatment involves collaborative goal setting at both the onset and throughout therapy as well as actively discussing techniques that are found to be most helpful. In order for therapy to be most successful, it is recommended you work on things we talk about both during and outside of our sessions. If at any time during your treatment you have questions or concerns about our work together, please bring them to my attention. Psychotherapy can have benefits and risks. Because therapy involves discussing difficult aspects of your life, you may experience uncomfortable feelings like sadness, guilt, frustration, anxiety, or anger. Therapy is not meant to be harmful or hurtful in anyway. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to improved relationships, solutions to specific problems, and significant reductions in distress. However, the results of therapy cannot be guaranteed. FEES You will be expected to pay for each session at the time it is held. You may pay by cash, check or credit card. The fee for a 50-minute session of individual therapy is $125. Bills that are 60 days past due may be placed in collection; I will inform you before I take this measure so that you will have the opportunity to pay promptly. If such legal action is necessary, the costs associated with that action, including attorneys’ fees, will be included in the claim and you agree to pay them. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. In addition to weekly appointments, I may charge the same rate (prorated according to length) for other professional services you need. Other services may include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, and preparation of records or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. CANCELLATION POLICY Once an appointment is scheduled you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, regardless of the reason for cancellation. I will make every effort to start our sessions on time. Sessions will end 50 minutes after the scheduled appointment time, even if you are late. If (on rare occasion) I have to begin our session late, I will make up the missed time in some mutually agreeable fashion (e.g., by extending the session, if convenient for you). If it becomes necessary for me to cancel an appointment with you with less than 24 hours notice, you will not be charged for the session. CONTACTING ME You may contact me or reach my voicemail. I am often not immediately available by telephone. My assistant monitors phone calls and email and will be able to answer most questions you have regarding insurance or scheduling. Should you need to speak with me directly, I ask that you give me 24-48 hours to respond since I am in session most of the day. If you are unable to reach me and feel that it is an emergency and you cannot wait for me to return your call, call -911, contact your psychiatrist or family physician, or go to the nearest emergency room. SOCIAL NETWORKING AND WEBSITES I do not engage in relationships via social media networks (Facebook, Twitter, LinkedIn, etc.) with current or former clients. Ethical guidelines, as well as legal statutes of our licensing board have strict regulations with regards to dual relationships, confidentiality, and professional boundaries, which prohibit such contact. CONFIDENTIALITY In general, the privacy of all communications between a client and a psychotherapist is protected by law, and I can only release information about our work to others with your written permission. In most situations, I cannot even confirm to a third party that you are being seen in my practice unless you agree to this. However, there are a few exceptions. These situations rarely occur, and if this type of situation occurs, I will make every effort to fully discuss it with you before taking any action. Limits to confidentiality include: * reasonable suspicion of child abuse or elder abuse * reasonable suspicion that you present as a risk to yourself or others * response to a legal proceeding such as court ordered therapy or subpoena for records or appearance Complaints about this counselor may be reported to: TX Dept of State Health Services @ 1100 W. 49th Street Austin, TX or 1.800.832.9623I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.* I Agree RECEIPT OF HIPAA I also certify that I have received a copy of the Notice of Privacy Practices detailing the provisions of HIPAA and my privacy rights.* I Agree CONSENT FOR EMAIL COMMUNICATION (optional) If you wish to contact me for basic communication purposes or to schedule appointments, you may call or email the office at ASSISTANT@COMPERIOCOUNSELING.COM. The decision of whether to have email contact with me is your decision. While email can be useful for scheduling or for exchanging information and resources, I do not recommend using email as a means to convey personal information. I do not offer advice, therapy, or emergency care via email as it is not a secure form of communication and the privacy of email exchanges cannot be guaranteed. I understand that email is not a secure means of communicating, and the confidentiality of communication through e-mail exchanges is not guaranteed. I consent to mutual communication with my therapist via e-mail.* I Agree Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms. 04. HIPAA Notice Contact Information*CHRISTY MELLEN, MEd, LPC Comperio Counseling PLLC 409.899.4600 firstname.lastname@example.orgName* First Last NOTICE OF PRIVACY PRACTICES (Health Insurance Portability and Accountability Act Provisions)*NOTICE OF PRIVACY PRACTICES (Health Insurance Portability and Accountability Act Provisions) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. PROTECTING YOUR PRIVACY Psychotherapists have always managed psychological records with great concern for privacy and confidentiality. Although the security of psychological records has continuously been addressed by Psychology Codes of Ethics as well as State and Federal laws, the rules have been considerably strengthened by the provisions of the Health Insurance Portability and Accountability Act (HIPAA). The following information provides details about the provisions of the HIPAA and your rights concerning privacy and your psychological records. WHO WILL OBSERVE THESE RULES? The following individuals are required by HIPAA to comply with the privacy rules: •. Your treating psychotherapist. This includes my therapist and/or anyone else with whom you consult for regular appointments. •. Any administrative assistant or office staff who may have some access to your identifying information (such as your name, address, telephone number, etc.). •. Any billing agency or collection agency that handles information about you (name, address, diagnostic codes, treatment codes, consultation dates, but not actual clinical records). YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding your medical information: The right to inspect and obtain a copy of your medical record: Professional records constitute an important part of the therapy process and help with the continuity of care over time. According to the rules of HIPAA, your consultations are documented in two ways: 1) The clinical record (required) may include the date of your consultations, your reasons for seeking therapy, diagnosis, therapeutic goals, treatment plan, progress, medical and social history, treatment history, functional status, any past records from other providers, as well as any reports to your insurance carrier; 2) Psychotherapy notes (optional), consisting of the specific content or analyses of therapy conversations, how they impact the therapy (including sensitive information that you may reveal that is not required to be included in your clinical record), and notes of your therapist that may assist in treatment. Psychotherapy notes are kept separately from your clinical record in order to maximize privacy and security. You have the right to inspect and obtain a copy of your clinical record. Viewing the record is best done during a professional consultation in order to clarify any questions that you might have at the time. You may be charged a nominal fee for accessing and photocopying the record. Psychotherapy notes, however, if they are created, are not disclosed to third parties, HMOs, insurance companies, billing agencies, clients, or anyone else. They are for the use of a treating therapist in tracking the many details of the consultations that are far too specific to be entered into the clinical record. The right to request a correction or add an addendum to your psychological record If you believe that there is an inaccuracy in your clinical record you may request a correction. If the information is accurate, however, or if it has been provided by a third party (previous therapist, primary care physician, etc.), it may remain unchanged, and the request may be denied. In this case you will receive an explanation in writing with a full description of the rationale. You also have the right to make an addition to your record if you think it is incomplete. The right to an accounting of disclosures of your psychological information to third parties You have the right to know if, when, and to whom your psychological information has been disclosed (exclusive of treatment, payment, and health care operations). However, you likely would already be aware of this, as you would have signed consent forms allowing such disclosures (e.g., disclosures to other psychotherapists, primary care physicians, specialists, etc.). This accounting must extend back for a period of six years. The right to request restrictions on how your information is used You have the right to request restrictions on certain uses or disclosures of your psychological information. These requests must be in writing. These requests will most likely be honored, although in some cases they may be denied. This office does not use or release your protected health information for marketing purposes or any other purpose aside from treatment, payment, healthcare operations, and other exceptions specified in this notice. The right to request confidential communications You have the right to request that your therapist communicate with you about your treatment in a certain way or at a certain location. For example, you may prefer to be contacted at work instead of at home to schedule or cancel an appointment, or you may wish to receive billing statements at a post office box rather than your home address. The right to receive a copy of this notice upon request You have the right to have a copy of this Notice of Privacy Practices. The right to file a complaint You have the right to file a complaint if you believe your privacy rights have been violated. You must do so in writing. Your complaint may be addressed directly to my therapist or to the Secretary of the Department of Health and Human Services. If you have any questions or concerns about this notice or this health information privacy, please contact your therapist. HOW I MAY USE AND DISCLOSE PSYCHOLOGICAL INFORMATION ABOUT YOU For treatment I will use psychological information about you to assist in the continuity of treatment and services. This information will not be shared with other health care professionals, however, unless you specifically request or agree to it and sign a consent form to that effect. For payment I may use and disclose psychological information about you for billing purposes. This is generally restricted to your name and other personal identifiers (address, and other relevant information such as social security number or Medicare number, or other needed information), diagnostic and treatment codes, dates of services, and similar information. For health care operations I may share basic identifying information with an administrative assistant or other office staff to assist in scheduling or other treatment procedures. This would not normally include the contents of your psychological record. As required by law It is possible (but unlikely) that the Department of Health and Human Services may review how I comply with the regulations of HIPAA. In such a case, your personal health information could be revealed as a part of providing evidence of compliance. Business associates I may contract with a billing agency or attorneys to attend to business aspects on an as-needed basis. In this case, there will be a written contract in place with the agency requiring that it maintain the security of your information, in compliance with the rules of HIPAA. Changes to this Notice Please note that this privacy notice may be revised from time to time. You will be notified of changes in the laws concerning privacy or your rights as I become aware of them. In the meantime, please do not hesitate to raise any questions or concerns about confidentiality with me at any time.I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.* I Agree Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms. 05. Video Therapy Informed Consent Contact Information*CHRISTY MELLEN, MEd, LPC Comperio Counseling PLLC 409.899.4600 email@example.comName* First Last Informed Consent for Video Therapy Session* Please read the following video therapy consent and sign below. 1. I understand that I am about to engage in a video therapy session with my provider, your therapist. 2. I understand that the video conferencing technology will not be the same as an in-person session with a provider due to the fact that I will not be in the same room as my provider. I also understand that, in order to have the best results for this session, I should be in a quiet place with limited interruptions when I start the session. 3. I understand the potential risks to this technology, include interruptions, unauthorized access and technical difficulties. I understand that my provider or I can discontinue the video therapy session if it is felt that the videoconferencing connections are not adequate for the situation. 4. My provider agrees to inform me and obtain my consent if another person is present during the consultation, for any reason. I agree to inform my provider if there is another person present during the session. 5. I understand that there are alternatives to a video therapy session available, including the option of finding another provider in my area. 6. I understand that I can direct questions about this video therapy session at any time to my provider, Christy Mellen. 7. I understand that this consent will last for the duration of the relationship with my provider, including any additional video therapy sessions I may have; I can withdraw my consent for a video therapy session at any time. 8. I understand that same confidentiality protections, limits to confidentiality, and rules around my records apply to a video therapy session as they would to an in-person session. 9. I agree to work with my provider to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during our sessions. 10. I understand that my provider may decide to terminate video therapy services, if they deem it inappropriate for me to continue therapy through video sessions. My provider will work with me to identify another provider for in-person care if they are unable. By signing this form, I certify: ● That I have read or had this form read and/or had this form explained to me. ● That I fully understand its contents including the risks and benefits of the procedure(s). ● That I have been given opportunity to ask questions and that any questions have been answered to my satisfaction. ● That I agree to participation in a video therapy session(s) with your therapist I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.* I Agree Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms. 06. Release of Information (as requested) Contact Information*CHRISTY MELLEN, MEd, LPC Comperio Counseling PLLC 409.899.4600 firstname.lastname@example.orgName* First Last Release of Information for Continuum of Care & TreatmentThis section should be completed if you want another counselor, psychiatrist or other healthcare professional to provide me with confidential medical, psychiatric, educational, and/or other appropriate information about you. Type of ReleaseTwo Way Release of information so Christy Mellen and the person listed below may share information with each other.One-Way Release of information so Christy Mellen may share information about me with the person listed belowName of Person or Organization Receiving Information* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Purpose: The specified recipient may use the health information authorized on this form solely for the following purpose(s):*Expiration: This authorization becomes effective immediately and shall expire on:* Date Format: MM slash DD slash YYYY My Rights:*My Rights: ▪ I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment. ▪ The recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me, or unless the use or disclosure is specifically permitted by law. ▪ I reserve the right to withdraw or revoke this authorization, in writing, at any time, except to the extent that my therapist has already disclosed the information. ▪ I have a right to receive a copy of this authorization.I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.* I Agree Client Signature*Type your full nameDate* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.