Out of suffering have emerged the strongest souls, the most massive characters are seared with scars. By Khalil Gibran About Me Please enable JavaScript in your browser to complete this form.We use this form to learn a little about you and the problem you are bringing to counselling or psycholtherpy. We have found it saves a great deal of time when it comes to a first session and prevents us from having subject you to a stream fo questions at a time when perhaps nervousness prevents you from thinking straight! We have tried to keep things as simple as possible. Please answer all questions as fully as possible. *(Requires a response.)Full Name: *FirstLastE-Mail Address: *Gender: *MaleFemaleAge *Address:Religion (If any):Who can we contact in case of emergency? E.g. friend, family member, general practitioner. Please include a telephone number. * Note: We will not normally contact this individual and will only do so if we assess you as being at serious risk. In the unlikely event that we need to contact him/her, we will only do so on a "need to know basis" and wherever possible, in consultation with you.Are you in paid employment? (copy) *YesNoPlease describe your occupation, paid or unpaid. If you are currently unemployed, please outline your former occupation or job for which your are trained. *Relation Status: *Married/Civil PartnershipDivorcedSeparatedLiving with partner/spouseIn a relationship but not living with partnerMarried Divorced or separated plus in new additional relationshipWidowedNot in a relationshipPlease check as many boxes as are applicable to you.Do you have any children? *YesNoAre you CURRENTLY prescribed or taking ANY form of medication? (This does not include over-the-counter preparations.) *YesNoNote: It is important that we know about all substances which might have an effect on your mood both during and outside sessions. All infromation provided here is held confidentially.If you answered Yes to the above question, please list your medications, indicationg what they are used for. If you answered No, please type "N/A". *Are you CURRENTLY receiving any form of counselling psychological therapy or psychiatric help? *YesNoIf you answered Yes to the above question, please detail or list the type of help you are receiving. If you answered No, please type N/A. *Have you EVER received any form of counselling psychological therapy or psychiatric help at any time in the past? *YesNoIf you answered Yes to the above question, please detail or list the type of help you are receiving. If you answered No, please type N/A. *Do you use recreational substances other than alcohol? *YesNoNote: It is important that we know about all substances which might have an effect on your mood both during and outside sessions. All infromation provided here is held confidentially.If you answered Yes to the above question, please detail or list the type of help you are receiving. If you answered No, please type N/A. *Please detail any major illness or condition, including disability you are experiencing or have experienced in the past.How would you describe your reason for attending counselling?CommentSubmit You can download the hard copy of the form to print. Donwload the hard copy Authorization For Disclosure Of Mental Health Treatment Information Please enable JavaScript in your browser to complete this form.I,whose Date of Birth isauthorize Holistic Self Care Counseling Services to disclose to and/or obtain from:the following information:Description of Information to be Disclosed (Patient/Client should initial each item to be disclosed)AssessmentEducational InformationDiagnosisDischarge/Transfer SummaryPsychosocial EvaluationContinuing Care PlanProgress in TreatmenPsychiatric EvaluationDemographic InformationTreatment Plan or SummaryPsychotherap Notes* (*Cannot be combined with any other disclosure)Medication Management InformationNursing/Medical InformationOtherPurpose This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations. If the purpose is other than as specified above, please specify: Revocation I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to [Insert Name] at [Insert Contact Information]. I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance on the authorization. ExpirationUnless sooner revoked, this authorization expires on the following date:or as otherwise indicated:Form of Disclosure Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically. Redisclosure I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy regulations, unless a State law applies that is more strict than HIPAA and provides additional privacy protections. I will be given a copy of this authorization for my records.Signature of Patient/Client DateClear SignatureSignature of Parent, Guardian or Personal Representative DateClear SignatureIf you are signing as a personal representative of an individual, please describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.).Check here if patient/client refuses to sign authorizatioCheck here if patient/client refuses to sign authorizatioSignature of Staff Witness DateClear SignatureNameSubmit You can download the hard copy of the form to print. Donwload the hard copy Financial Agreement And Cancelation Policy Please enable JavaScript in your browser to complete this form.Thank you for trusting Holistic Self Care Counseling Services as you embark on your mental wealth journey. Counseling sessions last 60 minutes for $150 per session which is due in full at the time of the session. Holistic Self Care Counseling Services does not currently accept any insurance at this time. Cancellations and/or rescheduling requires a 24 hour notice. A $50 no show fee will be charged to clients in the event of a missed visit not canceled within 24 hours of the scheduled session. Exceptions such as sudden illness or unforseen events will be put into consideration. Please call to let us know that you will be late for your session. It would be assumed that you are not coming if you are more than 15 minutes late for your appointment. In the event that you do not call to reschedule your session in 14 days, it will be accepted as your notice to discontinue counseling with Holistic Self Care Counseling Services.Client’s SignatureClear SignatureDateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920EmailSubmit You can download the hard copy of the form to print. Donwload the hard copy Counseling Agreement Please enable JavaScript in your browser to complete this form.CONFIDENTIALITY Confidentiality means that Holistic Self Care Counseling Services has a responsibility to safeguard information obtained during counseling/psychotherapy/Life Coaching. Confidentiality is adhered by Holistic Self Care Counseling Services also on teletherapy platforms. All identifying information about your assessment and treatment is kept confidential, except as mandated by law. You must sign a release of information before any information about you is given to anyone, except as mandated by law. In certain situations, mental health professionals are required by law to reveal information obtained during therapy to other persons or agencies without your consent. In such situations, it is not required to inform you of these actions. Please note the following exceptions to confidentiality. Confidentiality does not apply to cases of suspected abuse/neglect of children or the elderly.. Confidentiality does not apply to cases of potential harm to self or others. A mental health professional may disclose confidential information in proceedings brought by a client against a professional. Confidentiality does not apply to cases involving criminal proceedings, except communications by a person voluntarily involved in a substance abuse program. Confidentiality may not apply in cases involving legal proceedings affecting the parent-child relationship. Confidentiality may not apply to cases involving a minor child. In such cases, the mental health professional may advise a parent, managing conservator or guardian of a minor, with or without the minor's consent, of the treatment needed by or given to the minor. THE BENEFITS OF COUNSELING One major benefit that may be gained from participating in counseling is the resolution of the concerns brought to therapy. Other possible benefits may be a better ability to cope with marital, family and other interpersonal relationships, and /or a greater understanding of personal goals and values. THE RISKS OF COUNSELING There are certain risks involved in counseling. You may experience a variety of negative emotions during therapy as you remember and therapeutically resolve unpleasant events. Seeking to resolve concerns between family members, marital partners, and other persons can similarly lead to discomfort as well as relationship changes that may not be originally intended. The greatest risk of counseling is that it may not by itself resolve your concerns. Holistic Self Care Counseling Services will assess progress and provide referral to other sources if that is deemed necessary and appropriate. Psychotherapy is a collaborative process and the progress you make will depend in large measure upon your investment in the process. WRITTEN ACKNOWLEDGEMENT AND CONSENT TO COUNSELING I have read and accept this agreement and herewith consent to counseling/psychotherapy/Life Coaching treatment with Holistic Self Care Counseling ServicesClient’s SignatureClear SignatureDateMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameSubmit You can download the hard copy of the form to print. Donwload the hard copy
