ࡱ> q` 3GbjbjqPqP 4::X>@1@1@18x1\1?22222222`?b?b?b?b?b?b?$AhC?m622m6m6?22?A9A9A9m622`?A9m6`?A9A9 <l<22 ه-@168<T= ?0?@<,D7Dl<Dl<2>3|A93d4O222??19222?m6m6m6m6@1@1PT  New Client Information Referred By: _____________________________ Todays Date: _____________________ Are you currently in counseling elsewhere? ______Yes ______No Are you currently under probation and/or parole? _________Yes _________No Part I. Client Information Name: ____________________________________ Social Security #: __________________ DOB: __________ Age: _____ Male______ Female______ Name: ____________________________________ Social Security #: __________________ DOB: __________ Age: _____ Male______ Female______ Parent/ Legal Guardians Name (s) (under 18yrs.): ____________________________________ Address: _____________________________________________ City: __________ Zip: ________ Home Phone: ________________ Work Phone: _______________ Cell Phone: ______________ Which number would you like us to leave a message? _________________________________ **** The following information is optional, but will assist us in providing you the best-individualized services**** Marital Status: ___________________ Ethnicity: _______________ Religion: ___________ Sexual Orientation: _______________ Highest Level of Education Completed: _________ Emergency Contact: Name: ________________________ Phone: __________ Relationship: _______________ Part II. Individual Financial Responsible For This Account Name: ______________________________________ Relationship to Client: ________________ Address: ________________________________________ City: ___________ Zip: ___________ Email: __________________________________________ Social Security #: _________________ Work Phone: ________________ Home Phone: ________________ Cell Phone: _____________ Insurance Plan:____________________________________________________________________ Policy or Subscriber ID: ______________________________ Group ID: ____________________ Please list all other individuals living in the clients home. NameAgeRelationship to ClientSex1.2.3.4.5.6. Part III. Employment/ School Information Employment Status: ___ F/T ___ P/T ___ Student __ Retired __ Disabled __ Unemployed Place of Employment: _______________________Occupation: __________________________ School Attending: ________________________________________ Grade: _________________ Part IV. Health Status Current health issues: ____________________________________________________________ Do you have any allergies? ________________________________________________________ Primary Care Provider: _________________________________Phone: ___________________ Please list all medications you are currently taken and for what health/ mental health issues: ******list name of medication, dosage, frequency you take it and prescribing doctor*********** 1._______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________ 4. ______________________________________________________________________________ Part V. Mental/ Emotional Health History Have you ever had or currently have mental health related treatment? _____ Yes _____ No Are you under the care of a Psychiatrist? If so, whom: ________________________________ Please list the following information: Place/ TherapistDatesProblems Treating1.2.3.4.5.  Part VI. Reasons for Seeking Services (please circle all that apply): Emotional Health Relationship Issues Eating Disorder/ Body Image Life Improvement/ Coaching Parenting/ Family Issues Substance Use/ Abuse Career/ Work-related Issues Child/ Adolescent Issues Grief/ Bereavement Financial/ Legal Issues Trauma/ Abuse Marital/ Couples Conflict Self Esteem Adoption Issues Other: _________________ Please briefly explain how the above issues are currently affecting your life: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What are you hoping to accomplish by receiving services (counseling and/ or coaching) at this time: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you currently thinking about suicide or harming yourself in anyways? ___Yes ___ No Are you having thoughts about harming anyone else in any way? ___ Yes ___ No Are you currently using alcohol and/ or drugs? ___ Yes ___ No Service Contract Thank you for choosing (WCWA) Wholistic Counseling & Wellness Alternatives, LLC. This document contains important information about my professional services and business policies. Please take the time to read this document carefully before our first session. If you have any questions about the information, I will be more than happy to discuss them with you during our first session. After carefully reading this document, I will need you to print and sign your name completely. Your signature is required by law and verifies that you have read and been explained this information. Your signature also represents that you are agreeing to enter into treatment with me as well as agree to all of my business policies. At any time, you or I have the right to terminate this agreement in writing. Mental Health/ Wellness Services Wholistic Counseling & Wellness Alternatives, LLC. (WCWA) is a group of independent mental health professionals. Each mental health professional is independent in providing clinical services to their clients and each professional is fully responsible for those services. They are required to carry their own professional liability insurance and maintain professional records. Psychotherapy/ Counseling Psychotherapy/ Counseling are performed by a state licensed mental health professional. All therapist providing services are LCSW, LPC, LMFT, LISAC or any other a licensed mental health professional under direct supervision of an independent licensed professional. Each possessing their own individual training and therapeutic style, therefore, in order for your therapy to be a success, it is important that as a client you communicate your goals and problems with your treating therapist. Life/ Performance Coaching Life/ Performance Coaching are an alternative service to counseling/ psychotherapy. It is not intended to be equivalent to therapy, nor does it use the same approach. Coaching is designed for individuals that are generally functioning well in their lives, but desire an extra benefit. It focuses on the future and not the past, and is designed for individuals who have maintained emotional stability, but still desire to excel in their life. Coaching can be very beneficial in goal- setting, career planning and/or transitioning as well as self-esteem and personal growth. Anyone can benefit from life coaching. During your initial assessment and screening with WCWA, your treating professional will assist you in determining if coaching or counseling/ therapy is needed. The first 2 to 3 sessions will involve a thorough assessment of your needs. During this time, we can both decide if I am the best professional to provide the services, you need to reach your goals. After the assessment, you will be provided with a psychosocial summary of preventing problems as well as treatment goals proposed to address your concerns/ problems. It is very important that you consider your feelings regarding the first 2 to 3 sessions to make sure you are comfortable working with me. Personal Disclosure Statement and Informed Consent Please carefully read and initial each line on the space provided. ____ I understand that Christian F. Johnson, MS, LCSW is a Licensed Clinical Social Worker in the state of Arizona. I understand that all treating professionals with Wholistic Counseling & Wellness Alternatives, LLC. are licensed professionals in the state of Arizona. ____ I understand that Wholistic Counseling & Wellness Alternatives, LLC. does not provide 24-hour crisis counseling or services. If I experience a mental health emergency or crisis, I will immediately contact the crisis line at 602-222-9444 or if life threatening, I will immediately contact 911 for assistance. ____ I understand that our contact will be limited to services provided during scheduled sessions except in cases of emergency. In cases of emergency, after I have contacted the crisis line and/or 911, I will leave a message for my treating professional at 623.478.0452 and can expect to receive a return call within 24hrs. ____ I understand that we will meet weekly or bi-weekly as determined, for approximately 50 minutes. If I arrive late, I understand my session time will be shorter, but I will still be required to pay my full session rate. ____ I understand that, although counseling has many positive outcomes and benefits, during the process I may experience temporary distress or negative feelings associated with the issues addressed. I agree to initiate a discussion with my treating professional so that my concerns can be addressed. ____ I understand that I am voluntarily entering into counseling and/or services and therefore, am in control of my services and may choose to end my therapeutic relationship at any time. If at any time, I am dissatisfied with my treating professional and/or WCWA, LLC, and feel that my patient rights have been violated, I have the right to let them know. If I do not feel comfortable resolving complaints with my therapist or WCWA, LLC, I can file a formal complaint with the AZ Board of Behavioral Health Examiners at 602-542-1882. ____ I understand that it is possible that my life and the lives of treating professionals and/or WCWA, LLC staff my cross in social situations. In order to respect my confidentiality, my treating professional and WCWA, LLC staff will not initiate contact. ____ I understand that the rate for an initial consultation is $180 per hour and the time of the initial consultation may vary according to client needs. I also understand that all subsequent sessions are $90 for Individual and $120 for Family/Marital/Couples sessions. All fees are based on a 50-minute session, and if I go over more, I will be charged for additional time in 15-minute increments. ____ I understand I will be charged $90 per hour for other professional services I may need including: report writing and treatment summaries, telephone conversations lasting longer than 7 minutes, attendance at meetings with other professionals and any other professional services per your request. ____ I understand if I become involved in legal proceedings that require my treating professionals participation (in the form of a subpoena), I will be expected to pay for his/her professional time, including preparation, attendance time and transportation costs. Because of the complexity of legal involvement, WCWA, LLC charges a $1,000 retainer fee and $185 per hour with a four- hour minimum requirement for preparation, travel time, and attendance at any legal proceeding. In addition, a $1,000 retainer fee will need to be paid in advance. ____ I understand that I may apply for a reduced fee rate if my combined household income is below $ 40,000. I understand that meeting this income guideline does not guarantee that I will receive the reduced fee rate, as there are limited spaces available. ____ I understand that all fees for services are due at the time of each session. Appointments for future sessions cannot be made until I have paid my balance in full or I have made other approved payment arrangements. ____ I understand that if I am using medical insurance and/or a mental health benefits, my therapist may release information about my treatment to my insurance provider for utilization management, billing and claims, coordination of care with other treating professionals as required and deemed necessary. ____ I understand that WCWA, LLC takes cash, check and most major credit cards as payment methods. If I write a check, and it is returned, I will be charged a $35 returned check fee and may be required to make all cash payments for all future appointments. ____ I understand that I am responsible for canceling my scheduled appointments 24 hours before my scheduled appointment time. Appointments that I do not cancel 24 hours in advance I will be required to pay a $45 fee. ____ I understand that if I do not show up for a scheduled appointment and have not called and cancelled, I will be charged my full fee for the missed appointment. ____ I understand that my records and all my communication with my treating professional and/or WCWA-Wholistic Counseling & Wellness Alternatives, LLC. becomes part of the clinical record. Records are the property of Wholistic Counseling & Wellness Alternatives, LLC. Adult records are disposed of seven (7) years after the client has stopped receiving services, and minor records are kept until the minor child reaches age 18 or five (5) years after the minor childs 18th birthday, whichever is longer. ____ I understand that if Wholistic Counseling & Wellness Alternatives, LLC. is sold, moves or goes out of business, I will be notified in writing where to locate and request a copy of my clinical record. ____ I understand that children under the age of 18yrs. who are not emancipated, on leave from military duty, and/ or married, their parents should be aware that the law gives client rights to the parent. Therefore, the parents have access to the minors treatment records. If there is concern that abuse or neglect of the child is taking place by a caregiver, the appropriate reports will be made and will attempt to involve parents/guardians as much as possible. ____ I understand that all my communication with my treating professional and WCWA, LLC is kept confidential and cannot be released without my written consent. However, the following are examples of circumstances or situations, according to HIPAA in which my information may be disclosed without my consent: I am a danger to myself or to someone else In situations where my treating professional suspects child, elder or spouse abuse I disclose sexual contact with another mental health professional If I am involved in legal action/proceedings, my records are subject to subpoena from the court. My treating professional is ordered by court to disclose information. I request and sign a written authorization to release my records. WCWA, LLC and/your treating professional is required by law to disclose information. I have read the professional disclosure statement and informed consent above carefully and understand the nature of the service providers and the limits of confidentiality outlined above. I have received and understand a copy of the Notice of Privacy Practices for this office. I solemnly swear that all of the above information is true to the best of my knowledge and I agree with all terms above. ________________________________________________ ________________________ Client or Parent/Guardian Signature Date ______________________________________________________________________________ Providers Statement I have reviewed and verified patient understands of the Professional Disclosure Statement and Informed Consent, and Limits of Confidentiality. ________________________________________________ ________________________ Treating Professional Signature and Credentials Date ________________________________________________ ________________________ Supervising Professional (if applicable) and Credentials Date     WCWA- Wholistic Counseling & Wellness Alternatives, LLC.  1130 E. 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