Regular Client Intake Packet

CLIENT INTAKE
Deaton & Deaton Counseling & Consulting
Client Name: *
Age: *
Race: *
Culture/Ethnicity:
Street Address: *
City: *
Zip: *
Phone: *
SSN: *
E Mail: *
example@example.com
Marital Status: *
Access to Transportation: *
Employer: *
Job Title:
In case of emergency, contact: *
Briefly explain why you are here: *
Current/Pending Charges? *

Yes No
If yes, please specify:
Currently on Parole/Probation? *

Yes No
If yes, provide name and contact info for PO
Recently incarcerated? *

Yes No
If yes, please explain why:
Past/Current DCBS case? *

Yes No
If yes, provide DCBS contact info:
Provide brief description of case details:
Court ordered to treatment? *

Yes No

Immediate family

	Full Name	Gender	Age	DOB	In Home?	Name of other parent
Spouse/Partner
Children
Children
Children
Children

Educational History:
Highest Grade Completed:
High School:
Graduation Year:
College:
Degree(s) Obtained:
Professional Certification and/or License(s):
Employment History:
Name of employer:
Dates of employment:
Name of employer:
Dates of employment:
Name of employer:
Dates of employment:
Military experience? *

Yes No
Branch?

Army Air Force Marine Corps Navy Coast Guard National Guard
MOS:
Years enlisted:
Active Restraining Order? *

Yes No

Order Details:

	Date of Order	Length of Order	County, State	Judge	Victim Name	Phone	No Contact?	No Violent Contact?
Restraining Order

Do you currently, or have you previously, had any feelings of wanting to harm or kill yourself or anyone else: *

Yes No
If yes, please explain:
Do you feel safe in your home? *

Yes No
If no, please explain:
Who currently lives in the home with you? *
Do you feel you are currently being mistreated in any way? *

Yes No
If yes, please explain:
Do you have any diagnoses for mental health issues, or think you do? *

Yes No
If yes, please list:
Have you received counseling or treatment in the past? If yes, please include dates: *
Do you have access to community based services? *

SA/MH/DDID Treatment History: *

	Treating provider/ Agency	Age Rage at Time of Service	Reason for Service (Sx/Dx)	Level of Care of TX(Outpatient, IOP, Residential, ect.)	Interventions Used (CBT, 12-step, EMDR, etc.)	Response to Interventions (Successful/Unsuccessful)
Treatment
Treatment
Treatment
Treatment

Is there a history of mental illness in your family? If yes, please explain: *
Child of divorce/ separation? *

Yes No
Did client witness or suffer neglect or abuse in the home of origin? *

Yes No
Were drugs/alcohol abused in the home of origin? *

Yes No
Is client an adult child of an alcoholic/addict? *

Yes No
Does the client have any dependent children? *

Yes No
Is the client currently separated (legally or otherwise) from their children? *

Yes No N/A
If yes, please specify:
Is client's family currently *

Intact Fragmented
Does client consider their family *

Supportive Toxic to their treatment
Is the client currently married or in a domestic partnership? *

Yes No
How do you describe your relationship(s) with your family? *
How do you describe your relationship(s) with your friends/peers *
Who do you rely on for emotional support? *
Do you have a Social Network &/or Support System? *

Yes No
History of Abuse:
History of Abuse:

You would rather discuss this in person with the counselor

Leave blank if there's no abuse to report

	Victim	Perpertrator	Brief description
Domestic Violence
Sexual Assault, Rape, or Exploitation
Community Violence
Emotional Abuse
Elder Abuse
Other

HISTORY OF Trauma:
History of Trauma:

You would rather discuss this in person with the counselor

Leave blank if there's no trauma to report.

	Trauma Type	Brief Description:
Abuse/Neglect
Kidnapping
Natural Disasters
Military/War
Violence
Criminal

LEGAL HISTORY:

Please leave blank if you would rather discuss this in person with your counselor.

	Describe Charges	Convicted?	Years of Conviction
Past Charges
Past Charges
Past Charges
Past Charges

Do you have any difficulty with sleeping; for example, falling asleep or staying asleep? *
Do you have any concerns regarding your sexual health or relationships? *
Do you ever restrict your eating, eat compulsively, or make yourself sick after eating? *
Briefly explain your Cultural / Religious / Spiritual / Existential Background and Beliefs. *
Experienced any significant losses? (ex; family/friend, pet, job, relationship; anything you feel is significant) *
Have you been in a substance abuse treatment program, attended AA or and 12-Step Programs? *

Yes No
If yes, please list all programs:
Have you ever overdosed? *

Yes No
If yes, please list substance(s) and if you received Narcan or medical treatment:
Have you ever utilized a needle exchange program? *
Are you currently enrolled in a Suboxone or Methadone clinic? *

Yes No
If yes, please list clinic(s):

Please check any of the following which you have used and answer accordingly: *

	First Use	Last Use	Route (Smoke, I.V., ect.)	Amount	Frequency
Alcohol
Amphetamines
Benzodiazapines
Cocaine
Crack Cocaine
LSD
Marijuana
Opiates
PCP/Bath Salts
Spice/K2/Salvia
Suboxone
Nicotine
Other

What is your hope in attending counseling? *
How did you hear about us?
By signing and dating below I, (fill in name below), verify that the information I have provided is correct to the best of my knowledge and I agree to what is checked below. By providing my signature, I consent that this information be used for the purpose of therapeutic data gathering and I understand that all information provided will be kept confidential* and secure. * Please see Confidentiality Form for all exceptions. *
PLEASE CHECK BOXES INDICATING YOU HAVE READ AND SIGNED ALL NECESSARY DOCUMENTATION. (Some of these documents are below) *

Consent to Treatment Confidentiality Agreement (HIPPA) Fee Agreement HIV/AIDS Information Clients Rights/Responsibilites Risk Management Procedures Request for Digital Image / Photograph Drug Screen Policy
Print Client Name *
Client Signature *

Clear
Client Signature Date *

Month Day Year
Date
Clinician Signature

Clear
Clinician Signature Date

Month Day Year
Date
Client Rights and Responsibility Statement
It is the policy of this agency to provide services of individuals in an effective and efficient manner. Services will be directed toward the individual’s health and rehabilitation and will be provided in the least restrictive setting possible.

An individual receiving services has the following rights:

1.To receive a Notice of Privacy Practices

2.To not be unlawfully discriminated against in determining eligibility for services

3.To be treated with consideration and respect for human dignity

4.To receive quality treatment regardless of race, gender, religion, ethnic background, disability, sexual orientation, age, or ability to pay

5.To give informed consent to treatment and be involved in planning your treatment

6.To receive individualized treatment, be informed about your treatment process, and review your treatment plan

7.To obtain one free copy of your records upon written request except as limited by law

8.To refuse treatment to the extent permitted by the law and to be informed about the possible consequences of your actions

9.To be involved in your discharge and aftercare planning

10.To be provided confidentiality and protection from any unauthorized disclosure regarding your treatment

11.To examine and receive an explanation of the fees of services

12.To submit grievances, opinions, and recommendations about the program or the services received through the internal grievance procedure of this agency, the Center Ombudsman, if any, or the Cabinet for Health Services Ombudsman

As an individual receiving services you have the following responsibilities:

1.To arrive on time, attend, and participate in all treatment sessions

2.To cancel any sessions that you are unable to attend

3.To make up any sessions which you missed

4.To be alcohol and drug free for all sessions that you attend with the understanding that if you arrive under the influence of alcohol and/or drugs, appropriate steps will be taken by the agency staff to ensure your safety and the safety of others

5.To actively work on your treatment plan goals

6.To pay for all services with the understanding that if you fail to pay for services received, your completed paperwork will not be forwarded to the appropriate agencies and noncompliance to the court

7.To protect the confidentiality of all participants in the program

8.To follow through with all of your treatment recommendations

9.If you sign in and do not attend group session, you will be discharged from the program permanently.
Client Signature *

Clear
Client Signature Date *

Month Day Year
Date
Clinician Signature

Clear
Clinician Signature Date

Month Day Year
Date
Standard Authorization For Disclosure of Mental Health Treatment Information
born on, (fill in DOB below) *
I, (fill in name bellow), *
Authorize Deaton & Deaton Counseling & Consulting to disclose to and/or obtain from (fill in name below) the following information: *
Description of information to be Disclosed *

Assessment Diagnosis Psychosocial Evaluation Psychological Evaluation Psychiatric Evaluation Treatment Plan or Summary Current Treatment Update Medication Management Information Presence/Participation in Treatment Drug Screening Results/All labs Nursing/Medical Information
Purpose *

Educational Information Discharge/Transfer Summary Continuing Care Plan Progress in Treatment Demographic Information Psychotherapy Notes (cannot be combined with any other disclosure)
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 at any time by sending written notification to Deaton & Deaton Counseling & Consulting, LLC, at 215 Montgomery Avenue, Georgetown, KY 40324. 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.
Expiration

Unless sooner revoked, this authorization expires on the following date: one year from current date
Conditions
I further understand that Deaton & Deaton Counseling & Consulting, LLC will not condition my treatment on whether I give authorization for the requested disclosure.
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 *

Clear
Client Signature Date *

Month Day Year
Date
Signature of Parent, Guardian, or Personal Representative *Please specify your role as the Personal Rep*

Clear
Parent Signature Date

Month Day Year
Date
Personal Representative Capacity for Authorization:
Check here if patient/client refuses to sign authorization

Yes
Signature of Clinician

Clear
Clinician Signature Date

Month Day Year
Date
Physical Health Status Questionnaire
Name *

First Name Last Name
Date *

Month Day Year
Date
Social Security #: *
HISTORY OF MEDICAL PROBLEMS:

If you are currently or ever have been treated for the following problems, type "yes" and describe in the space provided.
Problems with eyes, ears, nose, or throat? *
Glaucoma? *
Dizziness, fainting, headaches, fatigue, seizures? *
Chest pains, high blood pressure, heart attack, stroke, other heart disorders, blood diseases or hardening of the arteries? *
Cough, shortness of breath, asthma, chronic obstructive pulmonary disease or Any other respiratory problems? *
Ulcers or other stomach/bowel symptoms? *
Diabetes, thyroid, pancreas, liver, or jaundice problems? *
Disorders of the muscles, bone, back, or joint arthritis? *
Any allergies? *
Disorder of the skin, tumor, cancer, or severe infection? *
Problems with male/female reproductive system? *
Venereal (Sexually Transmitted) Disease? *
Menopausal? *
Are you pregnant? If so, how far along are you and are there any current complications? *
Infectious diseases (Tuberculosis, Hepatitis, AIDS) *
Do you drink alcohol or use other non-prescription drugs/street drugs (please give the amount and how often)? *
Have you experienced DTs or Blackouts? *
Do you smoke tobacco? If so, how many packs per day? *
Major health problems, hospitalizations, surgeries, or visits to the Emergency Room not listed? *
Are you currently under a Doctor's care? *
Is there a history of alcohol, drug abuse, depression, mental/emotional or other major illness in your family? *
Are you sleeping well? *
Do you use alcohol, drugs, or medication to help you sleep? (Please identify what you are using) *
NUTRITIONAL
Are you required to be on a special diet? *
Have you had a change of appetite or weight in the last 6 months? (If so, why and what is the weight change?) *
Do you diet? *
Do you use diet pills? (If so, please list) *
Have you ever gone more than one day without eating food, except when you are sick? (If so, for how long and why?) *
Are you allergic to any medications or ever had a reaction to any medication? (If so, please list what medications and the medication?) *
MEDICATION PROFILE

Please list all the medications (over-the-counter, prescription, and herbal remedies) you are currently taking. *

	Name of Medicine	Dosage	How Often	For How Long
Medicine
Medicine
Medicine
Medicine
Medicine
Medicine
Medicine

Treatment History: *

	Treating provider/ Agency	Age Rage at Time of Service	Reason for Service (Sx/Dx)	Level of Care of TX(Outpatient, IOP, Psych, ect.)	Interventions Used (Counseling, Medicine, Hospital procedure, etc.)	Response to Interventions (Successful/Unsuccessful)
Treatment
Treatment
Treatment
Treatment

Client Signature *

Clear
Client Signature Date *

Month Day Year
Date
Clinician Signature

Clear
Clinician Signature Date

Month Day Year
Date
DO NOT WRITE BELOW THIS LINE

Clinician Use Only
SUMMARY OF CLIENT NEEDS
Does the clinician believe this client has a medical condition that will interfere with participation in the program?

Yes No
Is there a need to refer this client for a medical consultation?

Yes No
If yes, what action did you take?

Referral to Family Physician Referral Refused
Clinician Signature

Clear
Clinician Signature Date

Month Day Year
Date
CLIENT/PSYCHOLOGIST SERVICE AGREEMENT / INFORMED CONSENT
Welcome to Deaton and Deaton Counseling! The following is a document outlining our services and policies. Though long and often complex, it is important you understand them fully as they represent an agreement between yourself and Deaton and Deaton. All questions and/or concerns will be addressed upon the completion of these documents, as well at any time in the future.
PSYCHOLOGICAL SERVICES
Psychotherapy consists of a relationship between two individuals in which each individual has a set of clearly defined rights and responsibilities. As a client in psychotherapy, it is important you understand your rights, the legal limitations to those rights, your responsibilities as a client, and my corresponding responsibilities as your therapist. All rights and responsibilities are explained in the following sections.

There are both benefits and risks to psychotherapy; risks which may include experiencing feelings of discomfort, such as anxiety, fear, frustration and helplessness to name a few. The process of psychotherapy often requires the discussion of unpleasant aspects of your life, however, it often leads to a significant reduction in feelings of distress. It has also been shown to help increase satisfaction in interpersonal relationships, one’s personal awareness and insight, as well as stress management and problem-solving skills. Therapy requires active effort on your part, which may include your working on things we have discussed outside of the sessions. Remember, there are no guarantees in therapy.

The first two to four sessions will involve a comprehensive evaluation of your needs, at the end of which initial impressions of what our treatment plan may include. Treatment goals will be discussed, and an initial treatment plan will be created; be sure to evaluate and assess your comfort level with both the treatment plan and myself as your therapist. Any questions about my procedures should be addressed whenever they arise; should any doubt(s) persist, I will be happy to help you find and schedule an appointment with another mental health professional for a second opinion.
APPOINTMENTS
Appointments will range from 45 to 60 minutes in duration, once per week at a time we both agree on; that time is reserved for you and you alone. If you need to reschedule or cancel a session, 24 hours’ notice is required; sessions canceled within 24 hours of your appointment time, as well as missed sessions without notice, are subject to billing for the agreed upon session amount. You are required to be on time for your sessions, otherwise you forfeit that time and the session will still need to end on time. Frequency of sessions is adjusted as needed.
PROFESSIONAL FEES
The agreed upon fee for your session(s) is $ (fill in below), due at the time of your session unless otherwise specified. Acceptable payment methods include cash, check or credit card; returned checks are subject to an additional $50.00 fee, and payment by check will no longer be an option. I reserve the right to utilize an attorney of collection agency to secure payment should you refuse to pay debts owed by you to Deaton and Deaton Counseling and Consulting, LLC.
PROFESSIONAL RECORDS
It is required that I keep records of the psychological services provided; brief records noting you were here, your reasons for seeking therapy, treatment goals and progress, diagnoses, topics of discussion, medical/social/treatment histories, records received from other providers, copies of records sent to others, as well as your billing records. You have a right to receive a copy of your records except in unusual circumstances, such as those involving danger to yourself or others. Remember, these are professional records and may be misinterpreted and/or upsetting to untrained readers; it is recommended initial reading of case files be done with myself or another mental health care provider. You have the right to request, in writing, that a copy of your file be made available to any other health care provider. Should any request for access be denied, you reserve the right to have my decision reviewed another mental health professional. All client records will be kept in a secure location in the office.
CONFIDENTIALITY
The privacy of all communications between a patient and a therapist is protected by law and may only be released with your written permission, with the following exceptions:

1) In legal proceedings a judge may order my testimony or request your records if he/she determines that the issues demand it.

2) If I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency.

3) If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

4) If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

These situations have rarely occurred in my practice, however, should one occur I will attempt to both make you aware and discuss fully the circumstances before taking any action.
CONSULTATIONS
I have often found it helpful to consult my clinical supervisor or other mental healthcare professionals about a case, during which confidentiality of my clients is maintained fully; consultants are also legally bound to maintain confidentiality. While this summary may prove helpful in informing you of confidentiality standards and its limitations, it is important we discuss and questions or concerns you may have as soon as they arise.
PARENTS & MINORS
Privacy in therapy is crucial, however, parental involvement can be essential in treatment progression. It is my policy not to provide treatment to a child/adolescent under the age of 12 years of age unless s/he agrees that I be able to share whatever information I consider necessary with the parent. When treating adolescents age 13-17, it is requested that an agreement between myself, the client and the parents be made allowing me to share general information about treatment progress, attendance and a summary of treatment upon completion. Any other form of communication will require client agreement, unless there is a threat to the safety and wellbeing of the client/others (see above section on Confidentiality); in which case every effort will be made to inform and discuss with the client my intentions and address any concerns or objections they may have.
CONTACTING ME
I am often not available immediately, in which case, you may leave a message on my confidential voice mail/e mail and I will get back to you as soon as possible. Correspondences will be addressed in the order of urgency, meaning it may take a day or two for me to respond. If you do not hear from me, or if I am unable to reach you, and you feel as if you cannot wait or keep yourself safe:

1) Contact your Primary Care Physician

2) Go to your local Emergency Room & request to see the Mental Health Professional on staff

3) Call 911 and ask to speak with the Mental Health Professional on call

Every attempt will be made by myself to keep you informed of any planned absences and provide you with the name and contact information of the mental health professional covering my practice.
ADDITIONAL RIGHTS
You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy, my specific training and experience, as well as expect that I will not have social or sexual relationships with clients or with former clients. If you find you are dissatisfied with the treatment you are receiving, please make me aware so that I may respond and adapt as your concerns arise. Such concerns will be taken seriously and handled with care and respect. It is within your rights to request a referral to another therapist and/or end therapy as any time.
RISK TO NON-COMPLIANCE WITH THERAPY
By not following the therapeutic suggestions, the patient may experience decreased effectiveness of treatment which can lead to the worsening of or increase in presenting symptoms. The potential result of such is a decline in mental and emotional health that may lead to relapse, physical ailments, hospitalizations, and decrease in general quality-of-life.
FORWARD-LOOKING STATEMENTS
Our discussion may include predictions, estimates or other information that might be considered forward-looking. While these forward-looking statements represent our current judgment on what the future holds, they are subject to risks and uncertainties that could cause actual results to differ materially. You are cautioned not to place undue reliance on these forward-looking statements, which reflect our opinions only as of the date of this presentation. Please keep in mind that we are not obligating ourselves to revise or publicly release the results of any revision to these forward-looking statements in light of new information or future events.
CLIENT CONSENT TO PSYCHOTHERAPY
Session Day: (Select preferred day of the week.)

Monday Tuesday Wednesday Thursday Friday
Session Time: (Preferred)

: Hour Minutes AM/PM Option
Session Fee: (discuss with clinician)
I, (fill in name below) have read, understand and agree to the terms outlined in this agreement. *
Signature of Client *

Clear
Client Signature Date *

Month Day Year
Date
Signature of Parent, Guardian, or Personal Representative

Clear
Parent Signature Date

Month Day Year
Date
*Please specify your role as the Personal Rep* Personal Representative Capacity for Authorization:
DEATON & DEATON COUNSELING & CONSULTING, LLC FEE SCHEDULE
EFFECTIVE 01/01/2019

ASSESSMENT & INTAKE FEE: $25-$150

DUI ASSESSMENT: $35

DV ASSESSMENT: $35

GROUPS & CLASSES: $20-$125 each

DUI WEEKLY CLASSES: $20 each

DUI 20-HOUR (PRI – 1ST OFFENSE): $200 (set of 7 classes)

DV WEEKLY CLASSES: $20 each

RE-INSTATEMENT FEE: $25 (with each re-instatement)

INDIVIDUAL COUNSELING: $50-$150/ 1 hour session

OUTPATIENT GROUPS: $20

INTENSIVE OUTPATIENT GROUPS: $75-$125

MENTAL HEALTH ASSESSMENT: $75-$250

FORENSIC EVALUATION: $2,500-$10,000

DRUG TESTING (UDS): $5-$25 (unless covered by insurance)

COURT APPEARANCE: $100-$150/ hour including travel to & from/minimum of 3-hours (Must pay in advance of date of appearance)

ALL FEES ARE DUE AT THE TIME OF START OF SERVICE, UNLESS INSURANCE BILLED.

INSURANCE WILL BE BILLED IN EVERY CIRCUMSTANCE APPLICABLE AND APPROPRIATE.

A SLIDING FEE SCALE IS AVAILABLE BASED UPON INCOME AND FINANCIAL CIRCUMSTANCES.
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult
Name: *
Age: *
Gender *

Male Female
Date *

Month Day Year
Date
If this questionnaire is completed by an informant, what is your relationship with the individual? *
In a typical week, approximately how much time do you spend with the individual? (Hours/week) *
Instructions: The questions below ask about things that might have bothered you. For each question, select the number that best describes how much (or how often) you have been bothered by each problem during the past two weeks.

0: None; not at all

1: Slight; Rare, less than a day or two

2: Mild; Several days

3. Moderate; More than half the days

4. Severe; Nearly everyday
1. Little interest or pleasure in doing things? *
2. Feeling down, depressed, or hopeless? *
3. Feeling more irritated, grouchy, or angry than usual? *
4. Sleeping less than usual, but still have a lot of energy? *
5. Starting lots more projects than usual or doing more risky things than usual? *
6. Feeling nervous, anxious, frightened, worried, or on edge? *
7. Feeling panic or being frightened? *
8. Avoiding situations that make you anxious? *
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? *
10. Feeling that your illnesses are not being taken seriously enough? *
11. Thoughts of actually hurting yourself? *
12. Hearing things other people couldn't hear, such as voices even when no one was around? *
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? *
14. Problems with sleep that affected your sleep quality over all? *
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home) *
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? *
17. Feeling driven to perform certain behaviors or mental acts over and over again? *
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? *
19. Not knowing who you really are or what you want out of life? *
20. Not feeling close to other people or enjoying your relationships with them? *
21. Drinking at least 4 drinks of any kind of alcohol in a single day? *
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? *
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor's prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? *
Should be Empty:

CLIENT INTAKE

Educational History:

Employment History:

History of Abuse:

HISTORY OF Trauma:

LEGAL HISTORY:

Client Rights and Responsibility Statement

Standard Authorization For Disclosure of Mental Health Treatment Information

Revocation

Expiration

Conditions

Form of Disclosure

Redisclosure

Physical Health Status Questionnaire

NUTRITIONAL

MEDICATION PROFILE

DO NOT WRITE BELOW THIS LINE

SUMMARY OF CLIENT NEEDS

CLIENT/PSYCHOLOGIST SERVICE AGREEMENT / INFORMED CONSENT

PSYCHOLOGICAL SERVICES

APPOINTMENTS

PROFESSIONAL FEES

PROFESSIONAL RECORDS

CONFIDENTIALITY

CONSULTATIONS

PARENTS & MINORS

CONTACTING ME

ADDITIONAL RIGHTS

RISK TO NON-COMPLIANCE WITH THERAPY

FORWARD-LOOKING STATEMENTS

CLIENT CONSENT TO PSYCHOTHERAPY

DEATON & DEATON COUNSELING & CONSULTING, LLC FEE SCHEDULE

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult