Consumer Information Sheet



Miki Gordon, PhD Counseling & Consulting

Client Information Sheet

I. General Information

Name: _______________________________________________ Date: _______________________________

Date of Birth: ___________________________ Social Security:___________________________________

Address: __________________________________________________________________________________

May we text appt reminders to you? [ ]yes [ ]no If yes, phone number: ______________________________

May we contact you via email? [ ]yes [ ]no

If yes, please provide email address: ____________________________________________________________

Gender: [ ]male [ ]female Marital Status: [ ]single [ ]married [ ]separated [ ]divorced

Religion: ________________________________ Primary language: _______________________________

Employer: ___________________________________ Job Title: __________________________________

Phone Daytime: ________________________________ Evening: __________________________________

May we leave messages for you? [ ]yes [ ]no

Who may we contact in case of emergency?

Name: _______________________________________ Phone: ___________________________________

Relationship: [ ]spouse [ ]parent [ ]relative [ ]other:__________________________________________

II Insurance

Insurance provider: _________________________________ Policy or ID Number: ______________________

Deductible:____________________________________ Co-pay: ____________________________________

Has deductible been met? [ ]yes [ ]no If no, remaining amount ____________________________________

Co-insurance? [ ]yes [ ]no Provider and ID number:______________________________________________

III. Medical

Primary Care Physician: _____________________________________________________________________

Please list any current or past medical conditions: _________________________________________________

__________________________________________________________________________________________

Current Medications (name, dosage): ___________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Past Hospitalizations (when, where, reason): _____________________________________________________

__________________________________________________________________________________________

IV. Treatment

Presenting Issue: ___________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

Have you ever attended therapy before: [ ]yes [ ]no

If yes, please list therapist and dates: ____________________________________________________________

__________________________________________________________________________________________

Please list any other services you receive (i.e., psychiatric care, mental health services, case management, etc.): __________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________

V. Client History

Please check any events or issues that you have experienced:

[ ] physical abuse

[ ] sexual abuse

[ ] domestic violence

[ ] anxiety

[] panic attacks

[ ] depression

[ ] rape

[ ] alcohol abuse/dependency

[ ] drug abuse/dependency

[ ] suicidal thoughts

[ ] suicide attempts

[ ] homicidal thoughts

[ ] homicidal attempts

[ ] psychiatric hospitalizations

[ ] grief/loss

[ ] anger outbursts

[ ] cutting

[ ] running away

[ ] fire setting

[ ] destruction of property

[ ] insomnia

[ ] change in appetite

[ ] head injury

[ ] bed wetting

[ ] memory problems

[ ] nightmares

[ ] incarceration

[ ] seizures

[ ] sexual behaviors

[ ] victim/witness violent crime

[ ]serious accident/injury

Miki Gordon, PhD, NCC, LPC-MHSP

Consumer Acknowledgement of Services

I. RIGHTS AND RESPONSIBILITIES

As a consumer of service, whether a youth/adult/parent/legal guardian I am aware that I have certain rights and responsibilities as a participant in the service.

I have the right to be treated with respect and dignity and to be free of abuse, neglect, exploitation and physical punishment. I have the right to treatment, including access to medical care and habilitation, regardless of age or degree of MH/IDD/SA disability.

I have the right of informed consent – to have services explained in a manner I can understand. To be informed what is to happen, expectations, benefits, hazards, and alternatives to the service. Informed consent offers me a way to participate in service planning and provision.

I have the right to have all information about myself and/or my family to be kept in confidence. Confidential information includes all forms, written, verbal, audio or videotapes, and electronic. Under law there are times when the right to confidentiality is no longer valid. These such times can be found in the General Statutes or in 45 CFR 164.512 of HIPPA and include:

a. Upon receipt of a court order to release information

b. In the event of a medical emergency

c. When there is suspicion of abuse and/or neglect

d. When there is a danger to self or others and/or threats of harm to self or others

Certain information about services may also be provided to an insurance or billing entity.

I have the right to choose a service provider agency or organization and to refuse service altogether. In the refusal of service, I take upon myself the consequences of such actions.

I am aware that program or service design may require restriction of basic consumer rights to maintain the consumer in a safe, healthy and nurturing environment.

I have the right to make complaints about the service of Dr. Gordon. I am responsible to communicate my complaint in writing to my counselor and her licensing board.

I am responsible to be an active participant in the plan of care/service.

X__________ I am aware and understand my rights and responsibilities as provided to me.

X_________ I am aware that I can refuse treatment.

INFORMED CONSENT

X_________ I am aware of the counseling services planned for myself/my child. I will participate in the development of a service plan and agree to its content. I am aware of the benefits and potential risks of the program/service. I have been provided the opportunity to discuss the plan of service and possible alternatives. I agree to participate in the program and understand my participation is voluntary. I agree to participate in outpatient counseling services offered by Dr. Gordon.

AUTHORIZATION TO PROVIDE SERVICE

X__________ I authorize Dr. Gordon to provide service to my child/myself/my family. I understand that participation is voluntary and I may discontinue service at any time. I understand that my insurance provider may be billed for the services received and the primary care physician may be contacted for authorization of these services. I understand that Dr. Gordon may be required to notify the referring agency of my participation, withdrawal, or dismissal from services, when applicable. I have full understanding of the items initialed above and will be provided with a copy of this form upon request. A copy will be retained in my child’s/my case record. I have been given the opportunity to ask questions and seek explanation for any items that I do not fully understand. I voluntarily agree to participate in the program/service as documented in my service plan.

Client Signature:__________________________________________________________ Date: ____________

Parent/Legal Guardian Signature: ____________________________________________ Date: ____________

Clinician: ___________________________________________________________________ Date: ____________

Miki Gordon, PhD, NCC, LPC-MHSP

Service Agreement

The following services are currently offered by Dr. Miki Gordon: individual and family therapy, comprehensive clinical assessment, development of an appropriate service plan, and referral to other community resources.

Services NOT offered by Dr. Miki Gordon include, but are not limited to: custody evaluations, court ordered evaluations, court testimony, medication management, inpatient treatment, substance abuse treatment, sex offender treatment, and case management. Dr. Gordon does not offer custody evaluations or related court testimony, and may refer to appropriate resource for custody issues. By signing this document, I waive my right to subpoena Dr. Gordon for custody hearings. If Dr. Gordon is subpoenaed to court for any reason by myself or an agent acting on my behalf, I agree to a fee of $200 per hour that will be billed to the client or guardian, and will include preparation and travel time.

Because Dr. Gordon also serves children and adolescents, she does not offer any type of treatment for those who are on a sex offender registry, have been convicted of offenses against minors or the elderly, or have pending charges for abuse of children or the elderly. I agree to disclose my offender status, and notify Dr. Gordon immediately if I am charged with any types of offenses listed above.

I am aware of the types of services offered by Dr. Miki Gordon. I agree that if I require services other than those currently offered by Dr. Gordon, I am responsible for securing those services elsewhere. I will have the cell phone number for Dr. Gordon or a designated alternative counselor in case of an emerging crisis to use after hours. Calls involving a crisis will generally be returned in 24 hours. In case of a life threatening emergency, consumers should call 911 or go immediately to the emergency room.

Dr. Miki Gordon may share office space with other practitioners who operate, not as partners, but instead as independent contractors who share no clinical responsibilities. Neither Dr. Gordon, nor any other healthcare provider, has any professional responsibility for any acts or omissions of other providers.

________________________________________ _____________________

Signature of Consumer Date

________________________________________ _____________________

Witness Date

NOTICE OF PRIVACY PRACTICES

OF

Miki Gordon, PhD, NCC, LPC-MHSP

Dr. Miki Gordon must collect timely and accurate health information about you and make that information available to members of your health care team in this agency, so that they can accurately diagnose your condition and provide the care you need. There may also be times when your health information will be sent to service providers outside this agency for services that this agency cannot provide. It is the legal duty of Dr. Gordon to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care.

The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within Dr. Gordon’s office, as well as reasons why your health information could be sent to other service providers outside of this agency.

This Notice describes your rights in regards to the protection of your health information and how you may exercise those rights. This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures Dr. Gordon uses to protect the privacy of your health information.

Please review this document carefully and ask for clarification if you do not understand any portion of it.

Client Acknowledgement

I have received Dr. Miki Gordon’s Notice of Privacy Practices, which describes their methods for protecting the privacy of my health information that is used in providing health care services to me.

_______________________________________________/_________________________

Client (or Personal Representative) Date

Note: Agency retains this signed page. Client retains the Notice of Privacy Practices document.

Professional Disclosure Statement

Consent for Treatment

Miki Gordon, PhD, NCC, LPC (NC), LPC-MHSP (TN)

4229 Fort Henry Dr., Kingsport, TN 37663

5170 Hwy 105 S, #1, Banner Elk, NC 28604

Phone: 828-260-2031

Qualifications:

Miki Gordon holds a Bachelor Degree in psychology (1998), a Masters Degree in School Counseling (2002), and a PhD in Counselor Education and Supervision (2015). She has been involved in providing clinical services since 2001, and has worked with children, adults and families in a variety of settings.

Consent to treat:

I freely give my consent to be treated by Dr. Miki Gordon. I understand that these services may include but are not limited to:

1. Assessment, evaluation, and diagnosis

2. Developing a treatment plan

3. Psychotherapy

4. Additional referrals as needed

5. Release of information as designated by written permission

6. Follow up treatment as needed.

I understand that I may deal with difficult emotional issues, which may, at times, lead to unanticipated emotional stress, as well as emotional improvement. I understand that there are no warrantees or guarantees of a particular outcome given or implied.

Miki Gordon treats families, couples, and individuals from a systemic perspective. Theoretically she applies a variety of treatment strategies that will best fit the client’s needs. These theoretical orientations include: cognitive behavioral therapy (CBT), solution focused therapy, family systems therapy, play therapy, Eye Movement Desensitization and Reprocessing (EMDR), and Moral Reconation Therapy (MRT). She assists her clients with a variety of emotional, personal, and relational problems. Miki Gordon does not discriminate or refuse professional services to anyone on the basis of race, gender, religion, national origin, or sexual orientation. If your need for services are greater than can be provided in an outpatient practice, Miki Gordon will make a referral for appropriate care. In case of an emergency please call contact 911, your local hospital emergency room, or other local community emergency services.

Confidentiality:

Relationships are built on respect, trust and honesty. Conversations with Miki Gordon will be confidential except in instances where there is a legal mandate to report. These situations are: 1) if you express an intent to harm yourself or someone else and 2) if a child or elderly/disabled adult has been abused or neglected. In addition, a court may order Miki Gordon to testify about your therapy. Also, information may be disclosed to your insurance company in order to obtain reimbursement for services or to determine eligibility or coverage. Information may also be disclosed for the purposes of supervision. Miki Gordon will make every effort to inform you regarding any decision pertinent to the confidentiality of the therapeutic relationship.

As part of her work with you, Miki Gordon will enter into your records a diagnosis of your condition. Be aware that this will remain part of your records. If you choose to release this information to your insurance company it will likely become part of your medical record.

Financial Arrangements:

Fees: Miki Gordon is an independent practitioner, and charges fees as established for her practice. A 24-hour notice is required for cancellation of appointments. Dr. Gordon reserves the right to bill the client for damages to office facilities caused by willful acts on the part of the client or their minor children.

Complaint procedure: If you are dissatisfied with any aspect of your treatment please discuss it with Dr. Gordon. If you cannot resolve the problem and would like to file a complaint you may contact the North Carolina Board of Licensed Professional Counselors, P.O. Box 21005, Raleigh, NC 27619-1005, (919) 787-1980 OR the Board of Licensed Professional Counselors, Licensed Marital and Family Therapists and Licensed Pastoral Therapists, 665 Mainstream Drive Nashville, TN 37243, (615) 741-5735

I have read, understand and received a copy of the above disclosure statement and consent to treat.

_____________________________________________________ ______________

Client’s signature Date

_____________________________________________________ ______________

Guardian/Parent Signature Date

_____________________________________________________ ______________

Witness Date

Miki Gordon, PhD, NCC, LPC-MHSP

Authorization for Release of Information

Miki Gordon, PhD, LPC-MHSP, NCC

4229 Fort Henry Drive, Kingsport TN 37663

Name of Client: ______________________________________________ Birthdate: _____________________

I authorize Dr. Miki Gordon to contact:

Name of person or agency: ____________________________________________________________________

Address: __________________________________________________________________________________

Phone: _______________________________________ Fax: _______________________________________

( Release of information to Dr. Miki Gordon

( Release of information from Dr. Miki Gordon

( To disclose/request information regarding: history, prognosis, diagnosis, assessments, evaluations, progress, treatment information, and treatment recommendations

( For the purpose of providing, coordinating and managing treatment

( Other (please specify): _____________________________________________________________________

*I understand that all information received will be treated as protected health information and kept confidential unless I authorize disclosure or when disclosure is otherwise allowed by state or federal law. I may revoke this authorization at any time by signing and dating the Authorization Revocation section below. Upon fulfillment of the above stated purpose(s), this consent will automatically expire after 12 months of signature date.

**I understand that federal law prohibits the disclosure of substance abuse information per the confidentiality and disclosure requirements of 42 CFR Part 2.

***I understand that federal law also includes the protection of HIV/AIDS information under G.S. 130A-143.

_________________________________________________ _____________________________________

Client or Legal Guardian Signature Date Signed

_________________________________________________

Relation to Client

_________________________________________________ _____________________________________

Witness__

_____on prior to this date are legal and binding.

_____.________. be treated as confid Date Signed

Authorization Revocation

I revoke the above authorization for release of information effective ________________________. I understand that any actions that were taken on the authorization prior to this date are legal and binding.

_________________________________________________ _____________________________________

Client or Legal Guardian Signature Date Signed

_________________________________________________ _____________________________________

Witness Date Signed

Miki Gordon, PhD

Counseling & Consulting

Fee, Cancellation, and Referral Policy

To make the best use of client and clinician time, all appointments are expected to be on time. If you are going to be late, please call and let us know. If you are going to be more than 20 minutes late, please cancel the appointment and reschedule. Please cancel any appointments 24 hours ahead of time.

It is important to be consistent with therapy. Without consistent services, progress towards goals can be delayed or not made at all. If a client misses several appointments, Dr. Gordon may choose to end services and/or refer to another agency.

Any client who does not come to an appointment and has not called ahead by at least 4 hours to cancel will be charged $50.00 per missed session. This fee cannot be billed to insurance, and is expected to be paid by the client or their legal guardian. We understand there are emergencies and will waive this fee in the event of a true emergency.

Fees for counseling are expected at the time of service unless other arrangements have been made. In the event that fees cannot be paid in a timely manner, the client may be referred to another agency or resource. In the event that event that clinician services are needed outside of regular treatment, and this requires a burden of time or expense, fees will be billed to the client or their legal guardian. This includes, but is not limited to, fees for court appearances, after-hours fees, writing assessments or reports, or copying of records.

Referrals may be made to other agencies or providers to best serve client needs. This may mean that Dr. Gordon will choose to end services and refer to another provider in order to secure the most appropriate services and maintain safety. Reasons for referral include, but are not limited to: clients who need additional time or services, safety issues, emerging diagnoses or issues that Dr. Gordon does not treat, or changes in insurance or payment ability.

I have read and agree to the fee, cancellation, and referral policy of Dr. Miki Gordon:

Client Signature:_______________________________________________________________ Date: ________

Parent/Legal Guardian Signature: _________________________________________________ Date: ________

Clinician:_____________________________________________________________________ Date: ________

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