CLIENT INFORMATION

Responsible Party Information:

Have you seen a therapist before: Y Any recent hospitalizations: Y or N If yes explain:

Jireh Counseling Center Disclosure Statement Verdale Goins, PH.D., LPC, CAC III 2000 25th Ave N Suite 103, Texas City, TX 77590 (346)874-7105

Ph.D. Clinical Pastoral Counseling, 1993 Evangelical Theological Seminary M.A.Theological Studies in Counseling, 1990 Vision Christian University Industrial Engineering, 1981 Southern Illinois University

TX Licensed Professional Counselor #77413 CO Licensed Professional Counselor #1404 CO Certified Addiction Counselor #4482 Ordained Minister

Competence and experience include 30 years with individual, couple, group, family, career and youth counseling in the Denver, Colorado area. Area includes group homes, foster care, intensive in-home, substance abuse, DUI, domestic violence, langer management, mood and anxiety disorders, blended family therapy, adjustment disorders, grief and loss, job problems, spiritual and phases of life issues. Counseling Approach is based upon a Cognitive Solution Focused model. The initial suggested approach is to determine the reactive behavior, emotional state, addiction, inappropriate thinking patterns and/or family dysfunctions. The initial assessment and data gathering shortens the early stages of counseling. The primary approach is based upon developing skills in cognitive thinking, understanding themselves and others to make better decisions, taking better care of themselves, and developing responsible actions consistent with the clients new understanding. Although our sessions might be intimate, psychologically our relationship will be strictly professional. You, the client, may terminate therapy at any time. If you desire the counsel of another therapist, do not hesitate to discuss this matter so that the Jireh Counseling Center therapist can develop adequate closure.

Fees, Therapy & Insurance If using insurance, each counseling session is scheduled for 45 to 53 minutes, leaving time for rescheduling and paperwork. Each private-pay session is scheduled for 60 minutes and the cost is $125. There is a $25 non-refundable deposit required for private pay clients. The deposit will be applied to the cost of your visit. All payments are due at the time services are rendered, unless prior arrangements have been made. Cancellations without at least a 24 hour notice are Signature Rescheduling/Cancelling Appointments It is the client's responsibility to notify this office at least 24 hours prior to cancellations. It is the client's responsibility to call and reschedule cancelled or missed appointments. You will be sent an invoice for $25 for late cancellations and missed appointments. Notify our office should you have an emergency situation. No free counseling sessions will be done over the phone. Signature Confidentiality Limits Privileged communication remain the rights of clients, however, if a court should subpoena the file of the client, then confidentiality may not be maintained. In addition, some courts have held that if an individual intends to take harmful, dangerous or criminal action against another or themselves, it is the counselor's duty to warn appropriate individuals, and may include, the client's intention to harm themselves. The counselor will take all possible steps to first share that intent with the client and every effort will be made to resolve the issue with the client before notifying the appropriate individuals.

Additional Client Rights and Important Information 1. You are entitled to receive information about methods used for therapy, the techniques used, duration of therapy (if known) and the structures. Please ask if you would like this information. 2. You can seek a second opinion from another therapist, or terminate therapy at any time. 3. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the State Board of Examiners and Professional Counselors. The information provided by and to the client during therapy sessions is legally confidential. The therapist cannot be forced to disclose the information without the client's consent. If you have any questions, or would like additional information, please feel free to ask. I have read the above and understand the counselor's responsibilities, my financial obligation, and my rights as a client. Testifying in Court Due to the nature of the therapeutic process, it often involves making a full disclosure of many confidential and intimate matters. It is agreed that should there be legal proceedings, neither you or your attorney, or anyone else acting on your behalf will call me to testify in court or at any preceedings; nor will a disclosure of the psychotherapy records be requested. However, if I should receive a subpoena by the court, you will be responsible for my individulal hourly court fee of $300, which is applied for all professional time allocated for my services (e.g. travel time, paperwork, etc

I also hereby give consent to Jireh Counseling Center for treatment

The State Board of Examiners of Professional Counselors established the rules under which this therapist provides services. The Board's address and telephone number are as follows: 1100 West 49th Street, Austin, TX 78756 1-800-942-5540

I hereby authorize the release of pertinent information acquired during my evaluation and treatment to my insurance company.

I hereby authorize that payments be made directly to the signed clinician, realizing I am responsible to pay any services not covered.

Verdale Goins, Ph.D., LPC TX License #77413