RECONCILIATION THERAPY CLIENT INFORMATION. Today s Date: Your Name: DOB: Age:

Transcription

1 RECONCILIATION THERAPY CLIENT INFORMATION Today s : Your Name: DOB: Age: Child s Name: DOB Age: Child s Name: DOB Age: Child s Name: DOB Age: Child s Name: DOB Age: Address: Street City State Zip Code Phone #1: HCW (circle one) Phone #2: HCW (circle one) Occupation: Business Name: Referred By: Marital Status (Please check): Single Married Separated In Process of Divorce Divorced In Case of Emergency, please notify: Contact Phone: Relation: Other Household Members: Name Age Birthday (month/day/year) 1

2 RECONCILIATION THERAPY CLIENT INFORMATION (CONT.) If re-married or cohabitating: Spouse/Partner s Name: Phone: Co-Parent s Information: Co-Parent s Name: Phone: Legal Information: Are you currently involved in any legal action? Yes No Your Attorney: Phone: Co-Parent s Attorney: Phone: Judge:_County:_ Case Number: Court Ordered? Yes No Other Professionals Involved (ie: Guardian Ad Litem, Public Defender for Child(ren), Parent Coordinator, etc: Name: Phone: Role: Name: Phone: Role: Name: Phone: Role: Name: Phone: Role: 2

3 RECONCILIATION THERAPY CLIENT INFORMATION (CONT.) Why are you here today? Have you participated in counseling in the past? If so, when and where? If treatment is successful, what will be different in your life? Your goals for Reconciliation Therapy:

4 CONSENT FOR TREATMENT I request and authorize Jaime G. Vogt, MS, LPC, to provide professional psychological services to my child, family and/or myself. These services may include assessment or evaluation, psychological, psycho-educational, counseling and/or psychotherapy in individual, group, or family formats; psycho-educational counseling or training; behavioral interventions, professional consultation, mediation, parent coordinating and any additional services or procedures listed below. I am aware that Jaime G. Vogt is a licensed professional counselor. As a client utilizing the services of a therapist, I understand that I have the right to ask any questions I may have about the process, methods, duration, and goals of counseling the right to discuss any concerns I may have about my progress in counseling, and the right to terminate counseling if I feel I am not making progress. I acknowledge receiving an explanation of the limits to confidentiality which is as follows: (1) in the event of concern for harm to self or to another person, Ms. Vogt will take steps to secure the safety of the parties involved (2) if there is a need to report child abuse or elder abuse, Ms. Vogt will follow the legal reporting requirements for mandated reporters and (3) should the court subpoena the records or order communication, Ms. Vogt will address this procedure with the client. All other events will require a signed release of information for identified parties. I authorize Forensic Consulting and Counseling, LLC to furnish confidential information including but not limited to diagnoses and financial information to any insurer, third party payer or welfare agency providing financial assistance for the services rendered. I assign and authorize payment directly to Jaime G. Vogt, MS, LPC of any insurance or health plan benefits otherwise payable to me. I certify that I have the required legal standing for myself or in the case of a minor child, have legal custody and/or other required legal right to authorize psychological services. A photocopy of this authorization and assignment is to be considered as valid as the original. 4

5 CONSENT FOR TREATMENT OF A MINOR Minor children to receive psychological or evaluative services (please list names and dates of birth): Child s First and Last Name of Birth By signing this consent form, I verify that as the listed child(ren) s custodial parent or legal guardian, I willingly consent and agree to their receiving psychological and/or evaluative services by Jaime G. Vogt, MS, LPC. I certify that I have legal standing to authorize these professional psychological/evaluative services, or that I have legal custody and/or other required legal standing to request and authorize professional psychological/evaluative services for my child(ren). 5

6 CLIENT RIGHTS Each client served by Jaime Vogt, MS, LPC shall enjoy all rights, benefits and privileges guaranteed by the laws and constitutions of the State of Oklahoma and the United States of America including the Substance Abuse Client s Bill of Rights. Exceptions are those specifically lost through due process of law. Each client can expect: 1. To be treated with respect and dignity. 2. The right to a safe, sanitary and humane treatment environment. To receive services in an environment which provides reasonable privacy, promotes personal dignity, and provides the opportunity for improved functioning. 3. The right to a humane psychological environment that protects from harm or abuse ( No client shall be neglected and/or sexually, physically, verbally or otherwise abused.) 4. The right to receive services or appropriate referrals without discrimination s to race, color, age, gender, marital status, religion, national origin, degree of disability, political belief, handicapping condition, legal status, and or the ability to pay for services. 5. The right to be provided with prompt, competent, appropriate services. 6. To be afforded the opportunity to participate in the treatment planning and consent, or refuse to consent to the proposed treatment unless these rights are abridged by a court or competent jurisdiction on emergency situations as defined by law. 7. The right to have your records treated in a confidential manner consistent with Oklahoma and Federal law. 8. The right to request the opinion of an outside medical or psychiatric consultant, at the expense of the client; and/or to request an internal facility consultation at no cost. 9. The right to assert grievances with respect to any alleged infringement of these stated rights or any other statutorily granted rights. 10. The right never to be retaliated against or subject to any adverse conditions or treatment services solely or partially because of having asserted any of the client rights listed in this document. 6

7 NO RECORDING AND PENALTY AGREEMENT I/we agree that I/we will NOT audio/video record ANY portion of my/our therapy, consultation, parenting coordinator meeting or evaluation sessions with Jaime G. Vogt, LPC without her expressed written consent. This agreement applies to any other party I have included in my/our sessions or asked to provide information to Jaime G. Vogt, LPC on my/our behalf. I/we understand that there is a $150, penalty that I/we agree to pay to Jaime G. Vogt, LPC for breaching this agreement. 7

8 FINANCIAL AGREEMENT FORM 1. There is no privileged or confidential communication for any party in reconciliation counseling. 2. All in-office sessions are based upon a 50-minute hour at the rate of $ per hour. 3. Payment is due at the time services are rendered. Payment in full is due upon receipt of any invoice. Release of any records or written reports will be contingent upon payment in full of any balance due. 4. Any written correspondence sent out and or written report is charged at the rate of $ per hour. 5. Ms. Vogt bills for any time she directly spends on your case. All telephone, consultation, paperwork preparation or otherwise communicating, and travel time will be billed to the nearest quarter hour (i.e., one hour seven minutes would be billed as 1.25 hours). 6. Cancellation of a scheduled appointment will require 24 hour notice in advance of the appointment. Unless there is an emergency or Ms. Vogt is notified 24 hours in advance, you will be responsible for payment of the entire session at 100%. 7. Court Appearance: If Jaime G. Vogt, MS, LPC is requested or subpoenaed by your attorney to appear in court, a retainer of $2, ($3, outside of Tulsa metro area) will need to be paid by you to Forensic Consulting & Counseling, LLC (10) ten days in advance of the scheduled court date. Ms. Vogt charges $ per hour for court preparation, consultation, file review and/or travel time. She charges $ per hour for her time spent in the courtroom. This fee is non-refundable unless Ms. Vogt is notified 48 hours in advance of a cancelled court appearance. You will then receive a refund of the unused portion of your retainer. 8. Your credit/debit card information may be kept on file. In the event there is an outstanding balance on your account, your card will be charged. There is a 5% administrative fee (of total amount charged) applied to all payments processed by credit/debit card. See attached Electronic Card Agreement. 9. You are responsible for payment of your total bill. In the event you fail to pay the above mentioned fees and expenses, you also agree to pay the reasonable costs of collection, to include reasonable attorney fees. 10. There is a $25.00 NSF fee for returned checks. If you bounce a check, all future payments must be made via cash, cashier s check, money order or credit/debit card. 11. If you and/or your attorney request a copy of the case file, we require a subpoena or court order. Copies are billed at $.25 per page, plus $160.00/hr. for time and mileage. Fees must be paid prior to the release of the records. By signing this form, I hereby acknowledge that I have read and understand this fee agreement. 8

9 ELECTRONIC CARD AGREEMENT - Optional Any fees (including, but not limited to, written correspondence, legal consultations, copies of the file or recorded tapes) remaining on your account after the report has been completed will be charged to your credit/debit card unless prior arrangements have been made. Type of Card: Visa MasterCard Discover Card Number: Expiration (mm/yy): 3 Digit Security Code: Billing Zip Code: Name on Card: By signing this form, I authorize Jaime G. Vogt, MS, LPC of Forensic Consulting & Counseling to charge my account for any unpaid balance. There is a 5% administrative fee (of total amount charged) applied to all payments processed by credit/debit card. 9

10 FORENSIC SERVICES DESCRIPTION AND FEES The word forensic means for court purposes. Any services requested that will be provided to the court is considered forensic services. The following is provided to describe these services and the associated fees: 1. Court Testimony - if Jaime Vogt, MS, LPC is needed for courtroom testimony or a deposition a subpoena will be required in addition to a $2, ($3, outside of Tulsa metro area) retainer fee to be received in this office no later than 10 days prior to the date of the court appearance or deposition. The expenses for a court appearance or deposition involve case review and reserving an 8 hour day for the trial/hearing/deposition. Preparation, consultation, document or tape review and travel are billed at $200/hour. Court room testimony and deposition is billed at $300/hour. The retainer fee is non-refundable whether my appearance is still needed or not. The day was reserved, so my office was closed for the day. However, if I am notified within 48 hours of the scheduled court appearance or deposition, I will refund you any unused portion of the retainer fee. If I am ordered to return to court or the deposition a second day, then there is an additional $1, that will be required to be paid prior to the day I am to appear (cash, cashier s check or money order only). Regardless of who is involved in your case, if your attorney is the court authority who issued the subpoena, you are the responsible party for all of my court fees. 2. Written Reports all reports, regardless of the service, are billed at $185/hour. Reports are not released until all balances are current. 3. Extended Forensic Evaluation a multi-session interview and comprehensive evaluation that requires a court order. These are billed at $4, for one child and $2, for each additional child. Minimum payment due at Intake appointment is $1, with remaining balance due within 2 months of the initial Intake appointment in the case. 4. Reconciliation Therapy a court order is preferred, but not required. Appointments are billed at $160/hour. Total due at Intake appointment is $ If you have any questions please do not hesitate to ask. I have read and understand the forensic services as described by Jaime G. Vogt, MS, LPC. 10