Counselingsupervision.com
MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907-7602
Email: michaelbaltimore@
INFORMATION FOR ONLINE CLIENTS
Welcome to my practice. I appreciate your giving me the opportunity to provide counseling to you and/or your child. I want you to feel comfortable with me and hopeful about meeting your goals of treatment. Please keep this sheet for future reference.
Because the idea of online counseling is new for many people, let's take a look at the process and the steps involved. Actually, once you start communicating online you'll find out just how easy it is. So here are the steps:
1. You must have a WebCam and Microphone connected (or built in) to your computer.
2. You must have an Internet connection.
3. You must complete the online documents and schedule a day & time to meet.
(You can take care of this through our private portal which is secure and private.)
4. Arrange to have a quiet space with no one overhearing or interrupting your session.
That's it. You can be sure that I will protect your privacy and work to make this a convenient and helpful process. There are a few other things that you need to know. First, in case of an emergency you should follow the same procedures required in face-to-face therapy when you cannot reach the clinician. That is, contact the nearest emergency room or call 911 for assistance. Second, an appointment is a commitment for our work. Please agree to be on time and notify me well in advance in case you need to cancel or reschedule. There is a $25 fee for a no-show appointment. Finally, any other services outside of the online therapy process, including reports or letters, will require additional fees.
With over 35 years of experience in providing counseling and teaching counseling, I will work hard to make our time together beneficial for your concerns. I believe in the brief therapy model and will work with you to establish a time frame from the beginning of our sessions to our final termination session. It is my hope that this will be a rewarding process for you during the time we spend together.
Thank you, again, for considering me and giving me the opportunity to help.
Michael Baltimore, PhD
Counseling Supervision Services
MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
Date of 1st Visit: _________________
Identification
Name of Client____________________________ Age ____ Sex ____ Birth Date ___________ Race _____
Address ________________________________City ____________ State ____ Zip ______ County ______
Home Phone _________________Work Phone ________________ Cell Phone________________
E-mail_________________________________________
Names and Ages of Household Members ______________________________________
______________________________________
______________________________________
PROBLEM OR STRESS INFORMATION
What are you experiencing and/or what has happened to bring you to seek counseling? __________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Previous Mental Health Care and Dates
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FOR ADULT CLIENTS
Marital Status: Married_________ Date of Marriage__________________ Single________ Live In _______
Divorced & Remarried (Dates) _______________________________________________________________
Widowed & Remarried (Dates) _______________________________________________________________
Names & Ages of children____________________________________________________________________
Your occupation _____________________ Employer: _________________________ How Long? __________
Spouse (if applicable): Name ____________________________DOB ____________Work Phone __________
Education ________________________
Occupation ______________________ Employer: __________________________ How Long? ___________
COMPLETE FOR ADULT or CHILD: General Health Information
Are you presently under the care of a physician? ____Yes ____No A psychiatrist? _____Yes _____No
Name(s) of Physician _________________________________________________________________________________________
Date of last physical examination ______________________________________________________________
Dates of surgical/Invasive procedures ___________________________________________________________
__________________________________________________________________________________________
List daily alcohol consumption ________________________________________________________________
List medication(s) taken regularly ______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________
Do you exercise? ______ Yes ______ No How often? __________________________________________
If you enter therapy with me, may I tell your primary care doctor or psychiatrist so that he or she can be fully informed and we can coordinate treatment? _____ Yes ______ No
Signature___________________________ Date ___________
REFERRAL
Who gave you my name to call? ______________________________________________
Address _____________________________ City __________ State _________Phone ___________________
May I have your permission to thank this person for the referral? ___ Yes ___No
To Send A Report? ___Yes ___No How Did This Person Explain I Might Be Of Help?__________________
_________________________________________________________________________________________
_________________________________________________________________________________________
INDIVIDUAL RESPONSIBLE FOR BILL
Person Responsible For Bill ________________________________________________
Relationship to Person Being Seen _____________________________
Best way to contact ______________________________________________________________
EMERGENCY CONTACT INFORMATION
Emergency Contact: Name ___________________________________ Relation________________________
Address (if different from above) ______________________________________________________________ Home Phone _______________ Work Phone ___________________ Cell Phone _______________________
PLEASE COMPLETE THE ADULT CHECKLIST OF CONCERNS IF YOU ARE AN ADULT CLIENT. THIS FORM IS LOCATED ON THE WEBSITE BELOW THE INTAKE FORMS.
PLEASE COMPLETE THE QUESTIONS FOR PARENTS FORM IF A CHILD OR ADOLESCENT IS BEING SEEN. THIS FORM IS LOCATED ON THE WEBSITE.
MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
FINANCIAL INFORMATION
I truly appreciate your choosing to come to me for help. As part of providing high-quality services, we need to be clear about financial arrangements.
Because of state and federal regulations now in place, I cannot accept health insurance payments for online services. I have attempted to respond to this, by making my fees reasonable. There is an important advantage to this process. Your health records will not be seen by anyone else including your employer or other third-party payers. This is important to note because there will be no outside person or agency seeing your information for any purpose. Our private and confidential records can only be accessed with your permission.
I accept online payment through our PayPal site with an account or with a credit card. I will accept other payment arrangement in advance of our meeting. You have the opportunity to pay for your session prior to beginning.
When an appointment is scheduled, that time is reserved and held specifically for you. If you do not show for our appointment and have not given prior notice, you will be charged a “no-show” fee of $25.00 and must pay this fee prior to your next appointment. I request 24-hour notice for cancellation of any scheduled session.
If you have questions at anytime about your bill, please contact me.
I have read and agree with the above statement. My signature indicates my acceptance of these financial arrangements.
Signed ____________________________ Date _________________________
MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
Confidentiality
I commit to keep confidential what you say in the counseling process. There are a few exceptions of which you need to be aware:
• Imminent Danger- The law states that if I judge that you are a danger to yourself or others, I am required to take action to prevent harm from occurring to you or others.
• Child Abuse- I am required by law to report all cases of actual or suspected physical, emotional, or sexual abuse or neglect of children to the appropriate authorities. Abuse to the elderly or disabled also requires reporting.
• Court Ordered- if a judge orders a release of our privilege or if I receive a subpoena I may be required to respond.
• Supervision/ Case Consultation- In order to provide quality care to you I participate in regularly scheduled peer supervision or consultation.
If your records need to be seen or if I need to communicate with another professional I will require an Authorization for Release of Information form to be completed and signed by you giving permission for the coordination.
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MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
Counseling, Confidentiality and Privacy Practice Agreement
I do hereby seek and consent to take part in the treatment with Michael L. Baltimore PhD. I am aware that the practice of counseling is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of treatment provided by Michael L. Baltimore PhD.
I agree to collaborate with my therapist for the purpose of assessment and evaluation of my current situation and to work together to identify appropriate goals and methods of achieving them. I understand that we will regularly review our progress.
I understand that over the course of therapy, whatever assessments, tests or other clinical care that is recommended will be fully explained to me and that I have the option to accept or reject such care.
I am aware that I may stop my treatment with this therapist at any time. I understand that I may have to deal with problems if I stop treatment before goals are achieved.
I understand that if payment for the services I receive here is not made, the therapist may stop my treatment. I am aware that I will receive a direct bill for any no-show appointments.
I understand that Michael L. Baltimore PhD is committed to quality care. I may contact him regarding any questions or concerns about the quality of my care.
I have read the above and I have also read and understand the limits of confidentiality.
I have had an opportunity to review the notice of privacy practices. I had an opportunity to ask questions to seek any clarification I needed about these important materials.
My signature below shows that I understand and agree with all of these statements.
_______________________________________ _________________________
Signature of client (parent or guardian for minor) Date
_______________________________________ _________________________
Witness Date
MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
Notice of Privacy Practices
This notice tells you how I'm making use of your health information, how I might disclose your health information to others, and how you can get access to the same information.
Please review this notice carefully and feel free to ask for clarification about anything in this material you might not understand. The privacy of your health information is very important to me and I want to do everything possible to protect that privacy.
We have a legal responsibility under the laws of the United States and the state of Georgia to keep your health information private. Part of my responsibility is to give you this notice about my privacy practices. Another part of my responsibility is to follow the practices in this notice. This notice takes effect on April 14, 2003 and will be in effect until it is replaced. I have the right to change any of these privacy practices as long as those changes are permitted or required by law.
Any changes in my privacy practices will affect how I protect the privacy of your health information. This includes health information I will receive about you and that I create here. These changes could also affect how I protect the privacy of any of your health information I had before the changes.
When I make any of these changes, I will also change this notice and give you a copy of the new notice.
When you are finished reading this notice, please take it with you at no charge. If you request a copy of this notice at any time in the future, I will give you a copy at no charge to you.
If you have any questions or concerns about the material in this document; please ask me for assistance and I will provide assistance at no charge to you.
Here are some examples of how I use and disclose information about your health information.
I may use or disclose your health information...
1. To your physician or other health-care provider who is also treating you with your written authorization.
2. To any person required by federal, state, or local laws to have access to your treatment program.
3. To receive payment from a third party payer for services I provide for you.
4. To anyone you give me written authorization to have your health information for any reason you want. You may revoke authorization in writing any time you want. When you revoke authorization it will only affect your health information from that point on.
5. To a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, I will give you an opportunity to object. If you object, or are not present, or are incapable of responding, and I use my professional judgment, in light of the nature of the emergency, to go ahead and use or disclose your health information in your best interest at that time. In doing so, I will only use or disclose the aspects of your health information that are necessary to respond to the emergency.
6. To appropriate authorities under Georgia Law in the following circumstances: Imminent Danger to you or others, Child Abuse or under Court Order.
I will not use your health information in any marketing, development, public relations, and related activity without your written authorization.
I cannot use or disclose your health information in any ways other than those described in this notice unless you give me written permission.
As a client, you have these important rights:
A. With limited exceptions, you can make a written request to inspect your health information that is maintained by me for my use.
B. You can ask me for photocopies of the information in part "A" above.
C. I will charge you $.10 per page for making these photocopies.
D. You have a right to a copy of this notice at no charge.
E. You can make a written request to have me communicate with you about your health information by alternative means, at an alternative location (an example would be if your primary language is not spoken by Ms. Baltimore, and I am treating a child of whom you have lawful custody.) Your written request must specify the alternative means and location.
F. You can make a written request that I place other restrictions on the ways I use or disclose your health information. I may deny any or all of your requested restrictions. But if I agree to those restrictions, I will abide by them in all situations except those that in my professional judgment constitute an emergency.
G. You can make a written request that I amend the information in part "A" above.
H. If I approve your written amendment, I will change our records accordingly. I will also notify anyone else whom they have received this information, and anyone else of your choosing.
I. If I deny your amendment, you can produce a written statement in my records disagreeing with my denial of your request.
J. You may make any written request that I provide you with a list of those occasions where I or my business associates disclosed your health information for purposes other than treatment, payment, or my business operations. This can go back as far as six years, but not before April 14th, 2003.
K. If you request the accounting in "J" above more than once in a twelve-month period I may charge you based on our actual cost of tabulating these disclosures.
L. If you believe I have violated any of your privacy rights, are you disagree with a decision I have made about any of your rights in this notice, you may complain in writing to:
Compliance Officer: MICHAEL L. BALTIMORE PHD
Licensed Marriage & Family Therapist
Licensed Professional Counselor
2901 University Avenue, Mission Square, Suite 38
Columbus, GA 31907
M. You may also submit a written complaint to the United States Department of Health and Human Services. I will provide you with an address upon written request.
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