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ADULT INTAKE FORMDate: __________________________Client Name:___________________________________ Spouse’s Name: _______________________________ (if married)Address______________________________________________ City_________________ Zip______________Cell/Home Phone : _______________ Work Phone : ______________ Email: ___________________________Emergency Contact: ____________________ Relation:______________ Ph.#____________________________Age: ____________ D.O.B. _________________ Marital Status: Married|Single|Divorced|Remarried|Widow(er)Occupation: ___________________________ Employer: ____________________________________________Religious Affiliation ___________________ Church Attending________________________________________Marital History: Never married ______________1st Marriage: Date(s) ______________Spouse____________ Children and Ages_________________________2nd Marriage: Date(s) _____________Spouse____________ Children and Ages_________________________3rd Marriage: Date(s) ______________Spouse____________ Children and Ages_________________________Who has custody of your minor children: __________________________________________________________Briefly describe your reasons for seeking help:Would you like to use your health insurance to be reimbursed for session fees? Yes | NoHow did you hear about Anchor of Hope? Circle the best answer:Online Google Search Psychology TodayOther: ________________________________________________________________________Statement of ConfidentialityThe Client-Therapist relationship offers confidentiality in so far as allowed by the laws of the State of Colorado. Under certain conditions, the right to confidentiality is necessarily violated. There are four major exceptions to confidentiality that Colorado law requires all mental health professionals to report:Incidences of child or elder abuse or neglect.Intent to commit suicideThreats to do harm to yourself or another person.Court orderThank you for completing this form.PLEASE SIGN AND RETURN TO THERAPISTBy signing this document, I certify that I am the client or am duly authorized to furnish this information. I understand that I am responsible for all charges whether paid by insurance or not. I also authorize the release of any information by the therapist necessary to secure payment of fees.Signature: _____________________________________________ Date: _________________________Have you had previous psychological counseling or psychiatric help? Please check all that apply.MethodWhenWhereWhat were the issues?IndividualGroupMarriageHospitalization(s)List any health problems for which you are currently receiving treatment: ___________________________________________________________________________________________________________________________Medication(s): __________________________________________________________________________________________________________________________________________________________________________FAMILY HISTORYHistory in the Family:Mental Illness in family________________________________________________________________________Substance Abuse in family______________________________________________________________________Domestic Violence in family____________________________________________________________________Sexual Abuse in family________________________________________________________________________Physical Abuse in family_______________________________________________________________________Neglect in family_____________________________________________________________________________Suicidal Attempt(s) in family____________________________________________________________________Suicide in family_____________________________________________________________________________Custody Issues_______________________________________________________________________________History of Self:Self-Harm to Self (list methods)_________________________________________________________________Suicidal Attempt Self__________________________________________________________________________Neglected as a Child__________________________________________________________________________School Currently Enrolled______________________________________________________________________School History of being Expelled________________________________________________________________School Behavior______________________________________________________________________________Surgeries____________________________________________________________________________________Accidents___________________________________________________________________________________Age 0 – 5: Separation from mother_______________________________________________________________Age 0 – 5 Hospital stays________________________________________________________________________Strengths____________________________________________________________________________________Interests/Hobbies_____________________________________________________________________________Supports____________________________________________________________________________________Family Member Closest to______________________________________________________________________Circle Any of the following which are currently causing you difficulty:AngerHealthCareer choicesParentingMy PastDatingHopelessnessFoodAnxietySexual ProblemsMarriageReligionNightmaresPanic AttacksConcentrationFinancesPhobiaGriefWorkHeadachesAssertivenessSuicidal thoughtsEnergyAbuseAddictionParentsSleep TroubleViolenceDivorceHearing VoicesGuiltSadnessSelf-ControlDepressionStep-familyIn-lawsCuttingObsessivenessLegal IssuesOTHER AREAS ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES*This form is located on my website under new client forms. It is the client’s responsibility to download and read.*I, (Please Print Full Name) _____________________________________ have received a digital copy of Anchor of Hope Christian Counseling, LLC’s Notice of Privacy Practices.__________________________________________________________(Signature)______________________(Date)FOR OFFICE USE ONLYAnchor of Hope Christian Counseling, LLC attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:_____Individual refused to sign_____Communications barriers prohibited obtaining the acknowledgement_____An emergency situation prevented us from obtaining acknowledgement_____Other (Please specify)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DISCLOSURE STATEMENTFor Kevin Edwards, MS, LPCCDegrees and QualificationsCurrently a Licensed Professional Counselor Candidate (LPCC) with a Master of Science (MS) in Clinical Mental Health Counseling under the supervision of Stephen F. Anthony, LPC.EMDR (Eye Movement Desensitization Reprocessing) Trained through Maiberger Institute. Completed December 20th, 2019.Walden University, Minneapolis MN, Master of Science in Clinical Mental Health Counseling, 2017.Internship Completed at The Antioch Group, Inc. - Contemporary Christian Counseling under the supervision of Dr. Steven Hamon, Licensed Clinical Psychologist, 2017.University of Arkansas, Fort Smith AR, Bachelor of Arts in Psychology, 2008.Special Interests: trauma in adolescents, adults, older adults, EMDR, grief counseling, forgiveness therapy, anxiety, depression, OCDThe Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed psychologists, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, certified school psychologists, and unlicensed individuals who practice psychotherapy.The agency within the Department that has responsibility specifically for Licensed Professional Counselors (LPC) is the LPC Board, 1560 Broadway, Suite 1350, Denver, CO 80202. Their phone number is (303) 894-7766.Client Rights and Important InformationYou are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information.You can seek a second opinion from another therapist or terminate therapy at any time.In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed clinical social worker, a licensed marriage and family therapist, a licensed professional counselor, a licensed psychologist, or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist. If the information is legally confidential, the therapist cannot be forced to disclose the information without the client’s consent. There are exceptions to the general rule of confidentiality. These include: (1) Intent to harm yourself or others, (2) Abuse, suspected abuse of children or the elderly, or neglect or suspected neglect of children and (3) In the event that I am sued by you in a criminal or delinquency proceeding.In marriage and family counseling, the therapist holds a “no secrets” policy. All members of the couple or family system are treated equally and “secrets” are not kept by the therapist that requires differential discriminatory treatment of family members.If you have any questions or would like additional information, please feel free to ask during the initial session and any time during the psychotherapy process.CLIENT SIGNATURE, ACKNOWLEDGEMENT AND AGREEMENTI have read the preceding information and understand my rights as a client.______________________________ _________Client/Authorized Agent Signature Date (Counselor Copy)Copy given to Client? ______Therapist signature______________________________ Other Important Information Please be advised that while I have a Master’s degree in Counseling, what I offer is not intended to be a substitute for medical diagnosis and does not replace the services of a licensed physician or licensed psychiatrist. You agree and understand it is your responsibility to consult with your physician/psychiatrist for any specific medical problems. Further, you understand I may suggest you contact your physician or psychiatrist if I believe it’s advisable. In addition, you understand that any information shared during our sessions is not to be considered a recommendation that you stop seeing your physician or using prescribed medication, if any, without consulting with your physician/psychiatrist, even if after a session it appears and indicates that such medication or treatment is unnecessary. Education and TrainingCurrently a Licensed Professional Counselor Candidate (LPCC) with a Master of Science (MS) in Clinical Mental Health Counseling under the supervision of Stephen F. Anthony, LPC.EMDR (Eye Movement Desensitization Reprocessing) Trained through Maiberger Institute. Completed December 20, 2019.Walden University, Minneapolis MN, Master of Science in Clinical Mental Health Counseling, 2017.Internship Completed at The Antioch Group, Inc. - Contemporary Christian Counseling under the supervision of Dr. Steven Hamon, Licensed Clinical Psychologist, 2017.University of Arkansas, Fort Smith AR, Bachelor of Arts in Psychology, 2008.Acknowledgment and Consent to Receive ServicesBy signing this document and any attachments hereto, you agree that I have disclosed to you sufficient information to enable you to decide to undergo or forgo any of the approaches and other services I offer. You understand that your consent to the nature of our sessions is given voluntarily, without coercion, and may be withdrawn at any time in the future. You represent that you’re competent and able to understand the nature and consequences of our proposed sessions and agree to be personally responsible for the fees related thereto. You have read and understand the above disclosure about the services offered by me and my training and education and you have discussed with me the nature of the services to be provided, and except in the case of gross negligence or malpractice, agree to release, indemnify, hold harmless and defend Anchor of Hope Christian Counseling, LLC, its owners, managing partner, members, employees, representatives, and, consultants from and against any and all claims or liability, of whatsoever kind or nature, which you, or your representatives, may have for any loss, damage, or injury, including without limitation, physical, emotional, mental, financial, or personal, arising out of or in connection with your sessions.________________________________________________________________Client’s SignatureDate_________________________________________________________________Kevin Edwards, MS, LPCC DateFEE SCHEDULEThe standard fee for counseling as of January 1, 2020 is: $90 per fifty (50) minute individual counseling session. $100 per fifty (50) minute for family (multiple clients) counseling session. -------------------PAYMENT IS DUE AT TIME OF SERVICE OR IN ADVANCE-----------------------CHECK OR CASH ONLY. CHECK IS PREFERRED. A $15 administrative fee will be charged on all checks that are returned for non-sufficient funds. *Clients who must use credit/debit cards or pay through their bank account are required to set up a free Venmo account (Phone App) and pay their session fee. Your Venmo account must be set up at least 3 days prior to the session in order to allow time to authenticate your bank account. Due to increasing transaction fees, I no longer use Square for card payments. Payment from Venmo is due at time of service or in advance.First 15 minute phone consultation is free. Additional phone consultations are billed in 15-minute increments ($15 minimum). All calls over ten minutes will be billed accordingly. Time spent on written reports will be charged by my hourly rates. Charges for testing are additional.Any time needed to be spent in court will be charged at $300 per hour and will include preparation and travel time.*********CANCELLATIONS MUST BE MADE BEFORE 24 HOURS OF SESSION OR YOU WILL BE CHARGED A $40 CANCELLATION FEE.********* NO CALL/NO SHOWS WILL BE CHARGED THE FULL SESSION AMOUNT OF $90.Clients are seen on a fee-for-service basis only. I do not contract with any insurer. I will provide you with a receipt for the counseling service at your appointment that may be used to submit for reimbursements if you choose. I do not complete any insurance paperwork. You should know that if you select to use your health insurance plan to assist in the payment or treatment then you understand that your insurance carrier and the National Information Center will have access to your diagnosis code and other pertinent date needed for claim processing.All payments of all charges are the sole responsibility of the client receiving therapy or their legal parent or guardian. Payment is due at the time of service or in advance. The therapist is not responsible for the collection of payment from third party payers. Client is expected to pay the therapist in full and then collect from third party payers. In the event that you do not pay your bill, Anchor of Hope Christian Counseling, LLC reserves the right to seek payment through the use of a collection agency or through other legal means. The cost of collection will be added to your bill. I do hereby certify that I have read, understand and agree to the terms of this contract._____________________________________________________ __________________Signature of Client or Authorized AgentDate ................
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