COUNSELING FOR EMPOWERING CHANGE

COUNSELING FOR EMPOWERING CHANGE ANN CARLSON, LCSW 630-318-2805, ann.carlson5@gmail.com, anncarlsonlcsw.com 1010 Jorie Blvd., Suite 102 1105 Curtiss Street, 2 nd floor Oak Brook, IL 60523 Downers Grove, IL 60515 CLIENT BACKGROUND INFORMATION Date Client Name Date of Birth Status: Married Single Divorced Widowed Domestic Partner Occupation/Grade Employer/School Home Address City State Zip Home phone Cell phone Work phone Email Best place for me to leave a message (circle all that apply) Home Cell Work Email Text If you are using insurance, please complete the following: Insurance Company ID# Group # Insurance Company Address City State Zip Policy Holder Information (if different than client): Name Date of Birth Address City State Zip Relationship to Client Policy Holder Employer I/We consent to Counseling For Empowering Change to release all information requested by my insurance company, managed care company or EAP to secure benefit payments. I consent to the use of this signature on all insurance submissions. Signature Date Signature Date I/We consent to the payment of benefits directly to Counseling For Empowering Change, who accepts assignment. It is understood the undersigned has the responsibility for payment of services. Assignment of benefits does not release the undersigned from responsibility of payment. Signature Date Signature Date

Please describe the reason(s) you are seeking counseling at this time: What have you done in the past to manage the reasons you are seeking counseling? FAMILY INFORMATION Please list all members of the client s household: Name Relationship DOB Sex Occupation/Grade in School Custody arrangements (if applicable):

MEDICAL INFORMATION Primary Care Physician Address City State Zip Phone Medical conditions past or present treated by physician Psychiatrist Address City State Zip Psychiatric conditions past or present treated by psychiatrist Please list any hospitalizations for serious illness, psychiatric or surgery: Hospital Reason for hospitalization Dates/Year Please list any prescription or non-prescription drugs you are currently taking or have taken: Medication Start Date End Date Prescribed by For what condition Family history of serious illness:

MENTAL HEALTH INFORMATION Please list any previous counseling or psychological services: Date of Service Provider Purpose Reason for ending treatment Has anyone in your family been diagnosed with a mental illness (depression, anxiety, substance abuse OCD, bi-polar disorder, schizophrenia)? Yes No If yes, what is your relationship to the person? Have you ever engaged in self-injury? Yes No If yes, when was the last time you self injured? Briefly describe the type of self-injury, reasons for the self-injury SUBSTANCE USE INFORMATION Please indicate your current substance use and place an X under the appropriate column: Chemical None Daily Weekly Past Date of last use Caffiene Tobacco Alcohol Marijuana Cocaine Heroin Inhalants Prescription Other Do you consider your current chemical usage a problem? Yes No Do others consider your current chemical usage a problem? Yes No Are you in recovery from substance abuse? Yes No

CONSENT FOR TREATMENT AND GENERAL POLICIES Starting therapy is a big decision and you may have questions. We will do our best to answer any of your questions or concerns. This form explains our policies, state and federal law and your rights about mental health treatment. You should be aware that therapy is designed to be helpful, and it may also be difficult and painful at times. CONFIDENTIALITY AND EMERGENCY SITUATIONS Our conversations and our notes are not shared with anyone without your written permission, with these exceptions: 1. Diagnosis and dates of service shared with your insurance company to process your claims. 2. Information you tell us about physical, sexual or elder abuse; then, by Illinois state law, we will report this to the appropriate welfare agency. 3. When you sign a release of information to have specific information shared. 4. If you tell us you are in danger of harming yourself or others. 5. Information shared with our supervisor or consultant. 6. When required by law. Please be informed, Counseling For Empowering Change is not able to provide emergency services in times of imminent crisis. If you are in need of emergency services, please contact your medical doctor, your psychiatrist, call 911 or go to your nearest emergency room. DuPage County offers crisis intervention services and can be reached at 630-627-1700. Please know you have the right to review and receive copies of your client file. This file can be sent to another mental health professional, treatment facility, school or medical doctor, only with your written consent. I have read and understand the confidentiality policy and its limits and rights to records. Signature Date PAYMENT AND FEES Payment is due at the time of service. You understand you are fully responsible for all fees for services during the treatment period. If you are using insurance, it is your responsibility to understand your benefits, coverage and limits of coverage. If authorized by you to do so, Counseling For Empowering Change will submit claims to your insurance, but the final responsibility for payment is yours. Cash, check or credit card are acceptable forms of payment for services. To ensure payment, all clients are required to complete the attached credit card authorization form. Fees: Initial assessment - $150 60-minute session - $130 45-minute session - $110 No show or cancellation with less than 24 hours notice - $60 I have read and understand the payment policy and fee for late cancel or missed without notice session. Signature Date

PHYSICIAN CONSENT I hereby authorize Counseling For Empowering Change to discuss my mental health care with my primary care physician. I also authorize the release of any medical documentation to my primary care physician for the purpose of treatment. Primary Care Physician Phone Address City State Zip Signature Date It is your right to waive notification disclosing mental health care to your primary care physician. If you wish to waive notification, please indicate your reason as stated below: I WAIVE NOTIFICATION of my primary care physician to inform him/her I am seeking or receiving mental health services and direct you NOT to notify him/her. I do not have a primary care physician and do not wish to see one at this time. I therefore WAIVE NOTIFICATION to inform notification of a primary care physician. Notice of Privacy Practices: I have received and been provided to review the notice of privacy practices. Signature Date Consent for treatment of a minor: As the custodial parent or guardian of I(we) authorize and consent to services with Counseling For Empowering Change. Signature Date ELECTRONIC COMMUNICATION Electronic communication in the form of text message, email or voice mail cannot be guaranteed as confidential. Knowing this, please limit your electronic communication to appointments or schedule changes. If you wish to speak about your treatment at a time other than our scheduled appointment, please leave a brief message and we will contact you by phone within 24 hours to address your concerns. If you choose to leave us information about your treatment, please understand the limits of confidentiality and the risks associated with it. Please do not disclose information if you are at risk of harm to yourself or someone else via text, email or voicemail, since a timely response to a life threatening emergency cannot be guaranteed. If you are at risk of harm and need immediate assistance, please contact your medical doctor, go to the nearest emergency room or call 911. I have read and understand the electronic communication policy. Signature Date

COUNSELING FOR EMPOWERING CHANGE ANN CARLSON, LCSW 630-318-2805, ann.carlson5@gmail.com, anncarlsonlcsw.com 1010 Jorie Blvd., Suite 102 1105 Curtiss Street, 2 nd floor Oak Brook, IL 60523 Downers Grove, IL 60515 Symptom Checklist Name Date of Birth Age Date Review the following symptoms and mark the symptoms you are experiencing. PHYSICAL SYMPTOMS: headaches insomnia excessive sweating muscle ache daytime drowsiness increased appetite stomach aches diarrhea/constipation poor appetite other BEHAVIORAL SYMPTOMS: increased cigarette use cutting low motivation/energy increased alcohol use skin picking excessive energy increased illegal substance use binge eating poor self care excessive spending impulsive risk taking excessive exercise restricting food intake avoiding social contacts hair pulling poor concentration forgetfulness purging other EMOTIONAL SYMPTOMS: easily frustrated cry easily changing moods anger worried thoughts of suicide feel something bad will happen hopeless thoughts of homicide intrusive/upsetting thoughts racing thoughts irritable scared lonely sad other Do you currently feel suicidal? Do you have a plan and a means to kill yourself? Do you currently feel homicidal? Do you have a plan and a means to kill someone else?

COUNSELING FOR EMPOWERING CHANGE ANN CARLSON, LCSW 630-318-2805, ann.carlson5@gmail.com, anncarlsonlcsw.com 1010 Jorie Blvd., Suite 102 1105 Curtiss Street, 2 nd floor Oak Brook, IL 60523 Downers Grove, IL 60515 Credit Card Authorization Form Clients are required to have a credit card on file with Counseling For Empowering Change to receive services. If there is an unpaid balance, the credit card on file will be charged the unpaid balance 30 days after the invoice due date. The credit card on file will be charged $60 for a session cancellation less than 24 hours or a no show to a scheduled appointment. By signing this form, you acknowledge you understand and agree to the above authorization information. Signature to acknowledge Date Credit card information: Circle type of card: American Express Discover MasterCard Visa Cardholder s name (as it appears on the card): Credit card account number: Expiration date: Security code on back of card: Billing address: Cardholder s phone numbers: cell: home: work:

COUNSELING FOR EMPOWERING CHANGE ANN CARLSON, LCSW 630-318-2805, ann.carlson5@gmail.com, anncarlsonlcsw.com 1010 Jorie Blvd., Suite 102 1105 Curtiss Street, 2 nd floor Oak Brook, IL 60523 Downers Grove, IL 60515 Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices (Effective April 14, 2003) This notice describes how treatment information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Right to Privacy Health care providers are required by federal and state law to maintain the privacy of your treatment information. We are also required to give you notice about our privacy practices, our legal duties, and your rights concerning your treatment information. We must follow the privacy practices that are described while they are in effect (they went into effect April 14, 2003). We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. You may request a copy of the notice any time from us. Use and Disclosures of Treatment Information We will use information about your health care to provide you with treatment, to arrange payment for our services, and in conjunction with other health care providers, organizations, and professionals. The information privacy practices in this notice will be followed by any associate involved in your care and any business associate with whom we share health information. The following categories describe examples of the way we use and disclose treatment information: For treatment: We may discuss your treatment information with another mental health professional. For example, we may provide information to your health plan or other providers to arrange for a referral or consultation. For payment: We may use and disclose your treatment information to obtain payment for services we provide you, including but not limited to businesses in connection with billing and collection activities. For example, we may contact your insurer to verify benefits and obtain prior authorization to make sure they will pay for your care. Legal proceedings: We may disclose information in response to a court or administrative order, subpoena, discovery request, or other lawful process under certain circumstances. Scheduling appointments: We may use your phone numbers, email and text messages to contact you and leave messages to schedule or remind you of appointments. We may disclose information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose information to the extent necessary to protect your health or safety, or the health or safety of others. We will not disclose your treatment information if that disclosure is prohibited or significantly limited by other applicable law. Your Health Information Rights You have the right to: Inspect or copy treatment information that may be used to make decisions about your care with limited exceptions. You must make a request in writing by sending a letter to us at one of the addresses above. Request restrictions on uses and disclosures of your treatment information for the purposes of treatments, payment, or healthcare operations. We are not required to allow your request. If we do agree with your request, we will comply with it except to the extent that disclosure has already occurred or if you are in need of emergency treatment and the information is needed to provide that treatment. Inspect or copy treatment information that may be used to make decisions about your care, with limited exceptions. You must make a request in writing by sending a letter to us at one of the addresses above. Request that we amend or make changes to your treatment record. Your request must be in writing and it must explain why the information should be changed. Receive a list of instances in which we disclosed your information for purposes other than treatment, payment, or those disclosures you have authorized in writing. Request that we contact you by alternative means or at alternative locations. For instance, you may ask that we contact you at work. You must inform us in writing that alternative means are required. Receive a paper copy of this Notice and any amended Notices upon request. Questions and Complaints If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of Health and Human Services, Office of Civil Rights, 200 Independence Ave., S.W., Washington, DC 20201 (1-877-696-6775). There will be no retaliation for filing a complaint.