LONE STAR COUNSELING SOLUTIONS

BROOK ZEMEL, PH.D., LPC-S

COUNSELING INTAKE FORM

Note: This information is confidential.
Demographic Information:
Name: Date:
Age: Date of Birth
Relationship Status:   Single    Partner  Married  Seperated   Cohabitating  Divorced Widow 
# of Dependents: Gender:   Male    Female 
# Home/Mobile Phone:
Is it ok to leave a message for you at this number? :     Yes    No 
Work Phone:
Is it ok to leave a message for you at this number?     Yes    No 
Mailing Address:
E-mail Address: Skype Name:
Current Employer: Position Title:
Current Occupational Status: (i.e., F/T, P/T, self-employed, student, returning to work): 
How long on this Job: Do you enjoy your job?   Yes    No 
Education Level: Special Trainings:
Medical Doctor's Name/Phone: Psychiatrist's Name/Phone:
Emergency Contact Name:
ER Contact Relationship: Emergency Contact Phone:
How were you referred?: If online, which website?
1. PLEASE DESCRIBE YOUR REASON(S) FOR SEEKING TREATMENT AT THIS TIME (CARE). IF THERE IS A PARTICULAR EVENT WHICH TRIGGERED YOUR DECISION TO SEEK TREATMENT NOW, PLEASE LIST THE EVENT.
WHAT RESULT(S) DO YOU EXPECT FROM COUNSELING (LIST 2 OR 3 GOALS)?
2. Behavior - circle/highlight any of the following behaviors that apply to you:
Overeat Insomnia Suicidal attempts Vomiting Can't keep a job Smoke
Take drugs Take too many risks Compulsions Odd behavior Withdrawal Work too hard
Lack of motivation Procrastination Drink too much Sleep disturbance Nervous tics Crying
Eating problems Impulsive reactions Phobic avoidance Outbursts of temper
Loss of control Aggressive behavior Concentration difficulties
Are there any specific behaviors, actions, habits that you would like to change?
3. Feelings - circle/highlight any of the following feelings that apply to you:
Angry Guilty Unhappy Annoyed Happy
Bored Sad Conflicted Restless Depressed
Lonely Anxious Hopeless Contented Fearful
Hopeful Excited Panicky Helpless Optimistic
Energetic Relaxed Tense Envious Jealous
Others
4. CHECK ALL THAT APPLY TO YOU:
  Never Rarely Frequently Very Often   Never Rarely Frequently Very Often
Marijuana Heart problems
Tranquilizers Nausea
Sedatives Vomiting
Aspirin Insomnia
Cocaine Headaches
Painkillers Backaches
Alcohol Early morning awakening
Coffee Fitful sleep
Cigarettes Binge / Purge
Narcotics Poor appetite
Stimulants Eat "junk foods"
Hallucinogens Lack of interest in activities
Diarrhea Constipation
Compulsive Exercise High blood pressure
Use Laxatives Allergies
5. Physical - circle/highlight any of the following symptoms that apply to you:
Headaches Stomach trouble Skin problems
Dizziness Dry mouth Tics
Palpitations Fatigue Burning or itchy skin
Muscle spasms Twitches Chest pains
Tension Back pain Rapid heart beat
Sexual disturbances Tremors Unable to relax
Fainting spells Blackouts Bowel
Hear things Excessive sweating Tingling
Watery eyes Visual disturbances Numbness
Flushes Hearing problems Don't like being touched
Do you regularly exercise: What:  
How Often:  
6. HAVE YOU EVER HAD COUNSELING OR MENTAL HEALTH TREATMENT BEFORE?     Yes    No 
Reason: 
Outcome: 
7. PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING INCLUDING OVER THE COUNTER MEDICATIONS.
TREATMENT PHILOSOPHY
I BELIEVE IN WORKING TOGETHER TO ASSIST YOU IN MAKING THE CHANGES YOU FEEL ARE NECESSARY IN YOUR LIFE.
TOGETHER, WE WILL GATHER THE USEFUL INFORMATION NECESSARY FOR ME TO ASSIST YOU IN MAKING THESE CHANGES. WE WILL WORK TOGETHER, AS A TEAM, TO ATTAIN THE GOALS YOU SET FOR YOURSELF.
PAYMENT CONTRACT FOR LONE STAR COUNSELING SOLUTIONS
The following is a statement of the financial policy. It is requested that you read and sign this statement prior to beginning services. Full payment is due at time of service. Payment methods include: Check, Cash, PayPal, Visa/MC/Discover/Amex. A fee will be assessed to your account for all returned checks. Clients using charge cards sign below allowing the provider to automatically submit charges to the charge card after each session and can change payment information at any time.

FEDERAL TRUTH IN LENDING DISCLOSURE STATEMENT FOR PROFESSIONAL SERVICES

Part One     Fees for Professional Services
0 is charged per in-person (IP) session and per Skype (S) session (each defined as 60 minutes)
0 (IP) or (S) is charged for missed appointments or cancellations with less than 24 hours notice.
.50 (IP) or .50 (S) is charged for extended email/phone communication in 15 minute increments.
fee for 2 assessments with detailed analysis.
Note: discounts are offered for Skype sessions (see website for details).
I also take Blue Cross Blue Shield of Texas. Clients are responsible for co-pays and possibly costs associated with their deductible/co-insurance at each session. It is imperative that you check with your insurance company to determine what your costs will be.

Part Two     All Clients
Payments, testing/assessment fees, and related fees are due at the time of service. Services will be terminated if timely payment is not made as agreed to by this consent.

Part Three     Minors
The adult accompanying a minor (or guardian of the minor) is responsible for payments for the child at the time of service.


I HEREBY CERTIFY that I have read and agree to the above terms and conditions and accept full responsibility for payment of all fees at the time of the visit, unless other arrangements have been made.
Client's Name:                                       DOB: 
Person responsible for account              Date:  

PAYMENT AUTHORIZATION FOR SERVICES

PRIMARY INSURANCE INFORMATION/SECONDARY INSURANCE INFORMATION (IF APPLICABLE)
INSURED NAME  
INSURED SSN  
INSURED B-DAY  
EMPLOYER  
HEALTH PLAN  
CUSTOMER SERVICE PHONE NUMBER ON INSURANCE CARD 
MENTAL HEALTH PLAN (IF DIFFERENT)  
RELATIONSHIP TO THE INSURED  
MEMBER #  
GROUP/POLICY #  
Client's signature:

Date:

Informed Consent for Counseling Lone Star Counseling Solutions; Brook Zemel, Ph.D., LPC-S

I am licensed by the Texas Board of Examiners of Professional Counselors and am considered a Licensed Professional Counselor or L.P.C. In addition, I am an approved supervisor (LPC-S) of LPC- Interns (LPC-I). I received a Ph.D. in Counseling from Washington State University. I also have a Master of Science Degree in Education with a major in counseling from Indiana University- Bloomington. My training qualifies me to offer individual, couples, relationship, and/or group counseling. Sometimes, family sessions are utilized during treatment as well. If our work together indicates that there are issues beyond my personal expertise, I will refer you to an appropriate practitioner that may better provide necessary services.
Goals of Counseling: Counseling is a joint effort between the counselor and client, the results of which cannot be guaranteed. Progress depends on many factors including: motivation, effort, and other life circumstances such as interactions with family, friends and other associates. Electronic Transmission: I cannot ensure the confidentiality of any form of communication through electronic media. By law, E-mail correspondence is not considered to be a confidential medium of communication.
Records: I am required to maintain records of my work with you. These generally take the form of notes that I make during and after appointments, intake information, written information that you give me, billing information and correspondence. These records will not be released without your written consent, except in situations described under the page Limits of Confidentiality.
CLIENT RIGHTS: You have the right to inquire about my professional credentialing and experience as a counselor. You have the right to refuse a particular recommendation. You have the right to discuss concerns or dissatisfactions about our work together. You also have the right to end counseling at any time. (I do, however, encourage you to make a commitment to attend a final session before terminating). For violations of the Texas Administrative Code, contact: Texas State Board of Professional Counselors, Complaints Management and Investigative Section, P.O. Box 141369, Austin, Texas 78714-1369 or call 1-800-942-5540.
Cancellations and Missed Appointments: When you schedule an appointment, that hour is reserved expressly for you, therefore, if you fail to inform me at least 24 hours in advance, you will be billed at your normal fee. If you decide to terminate services, please let me know. If you fail to attend two consecutive sessions without notifying me, I will assume that you wish to terminate services. Billing Practices: Payment for services is expected at the time of service. Whether you file insurance or not you are responsible for full payment for services rendered, so if an insurance company denies payment, you are still responsible for the allotted amount of payment. It is very important that you check with your insurance company immediately prior to the time of service to verify coverage, deductibles and co-pays.
Fees: My standard fee for a 60 minute session is 0.00 (IP) or (S), with the exception of approved insurance companies and contracted fees for services from those companies. In the instance where assessments are used, there is a .00 fee for 2 assessments with a detailed analysis. Note: I accept cash, personal checks PayPal, and credit cards (see Payment Contract). Delinquent Accounts: There is a service charge for returned checks. Your name may be released to a collection agent if your account becomes delinquent. I will work with you in every possible way to avoid such an event.
AFTER HOURS EMERGENCIES: Emergency situations may necessitate immediate attention. Situations can escalate and become quickly unmanageable. If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact emergency services, their physician or psychiatrist, or go immediately to the nearest emergency room. You may also call 911. Emergencies are urgent issues requiring immediate action. I will follow those emergency services with standard counseling and support to the client or clien's family.
LIMITS OF CONFIDENTIALITY: All information shared will be kept confidential with the following exceptions: (a) you give me written permission to tell someone else, and I agree to do so; (b) I believe you are a danger to yourself or others; (c) you disclose a minor is being exposed to or is consuming substances that are potentially harmful; (d) you disclose abuse, neglect or exploitation of a child, elderly person or disabled individual; (e) in a previous counseling/therapeutic relationship, your counselor sexually exploited you; (f) for verification of insurance benefits and billing purposes; (g) if I receive a court subpoena for your records (h) if you are a minor (under age 18), your parents or legal guardians can have access to your records; and/or (i) you disclose prenatal exposure to controlled substances that are potentially harmful.
Insurance Providers (when applicable): Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of the impairment, progress of therapy, case notes, and summaries.

I agree to the above limits of confidentiality and understand their meanings and ramifications. I have read, understood, agree, and consent to the above conditions of service stated. I have also received the Notice of Privacy Practices on this date. I recognize that I have the opportunity now, and in the future, to discuss any questions I may have with Dr. Zemel.

Client Signature (Client's Parent/Guardian if under 18): 
Today's Date: 
 

NOTICE OF PRIVACY PRACTICES - LONE STAR COUNSELING SOLUTIONS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am required by applicable federal and state law to maintain the privacy of your health information and inform you of my privacy practices, legal obligations, and your rights concerning your health information. I must follow the privacy practices that are described in this Notice (which may be amended from time to time).
I am required to abide by the terms of the Notice of Privacy Practices that is most current. I reserve the right to change the terms of the Notice at any time. Any changes will be effective for all protected health information that I maintain. The revised Notice will be posted in the waiting room. You may request a copy of the revised Notice at any time.
I will answer your questions about my privacy practices and do ensure that I will comply with applicable laws and regulations. I will also take your complaints and can give you information about how to file a complaint.
I. USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION THAT MAY BE MADE TO CARRY OUT HEALTHCARE OPERATIONS.
I may use and disclose limited information from your record without your written authorization, excluding Counseling Notes as described in Section IV, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.
Treatment: I may use and disclose limited information in order to provide treatment to you. For example, I may use information to diagnose and provide counseling service to you. In addition, I may disclose information to other health care providers involved in your treatment.
Payment: I may use or disclose limited information from your record to obtain payment for the services you receive. For example, I may submit your diagnosis with a health insurance claim in order to demonstrate to the insurer that the service should be covered.
Health Care Operations: I may use and disclose information (not your name or other identifying information) from your record to allow health care operations including quality improvement activities, intern training programs, reviewing records to see how care can be improved, accreditation, certification, licensing or credentialing activities. For example, I may use information in your record to train another counselor.
II. YOUR INDIVIDUAL RIGHTS
Right to Inspect and Copy. You may request access to the information in your record maintained by me in order to inspect and make a copy of it. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested.
Right to Request Restrictions. You may ask to restrict the use and disclosure of certain information in your record that otherwise would be allowed for treatment or payment. You must request any such restriction in writing. I am not required to agree to any such restriction you may request. Right to Accounting of Disclosures. You have the right to request an accounting of any disclosures made by me.
Right to Request Amendment: If you believe information in your record is inaccurate or incomplete, you may request amendment of the information. You must submit sufficient information to support your request for amendment. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.
Right to Obtain Notice. You have a right to obtain a paper copy of this Notice upon request. Right to Complain. You have the right to complain to us about our privacy. You have the right to complain to the Secretary of the Department of Health and Human Services about our privacy practices. You will not face retaliation from us for making complaints.
Except as described in this Notice, I may not make any use or disclosure of information from your record unless you give me your written authorization. You may revoke an authorization in writing at any time, but this will not affect any use or disclosure made by us before the revocation. In addition, if the authorization was obtained as a condition of obtaining insurance coverage, the insurer may have the right to contest the policy or a claim under the policy even if you revoke the authorization.
III. USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION THAT I AM REQUIRED TO MAKE WITHOUT YOUR PERMISSION.
Communications between a counselor and client are privileged and may not be disclosed without your permission, except as required by law. For example, counselors must report suspected abuse/neglect of a child, elder, or disabled person. I may have to breach confidentiality if you appear to post an imminent danger to yourself or others, in order to reduce the likelihood of harm to you or others. Also, I must disclose information to the Department of Health and Human Services, if requested, to prove that I am complying with regulations that safeguard your health information.
I may disclose information from your record if ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, I may disclose information in response to a subpoena or other legal process, even without a court order.
You have a right to receive confidential communications from me. For example, if you want to receive bills and other information at an alternative address, please notify me. I may contact you to provide information or appointment reminders as a courtesy. Please notify me if I am not to leave a telephone message or use electronic communication. You are responsible for remembering your appointment, whether or not you receive a reminder.
I may contact you with information about treatment alternatives or other health-related benefits or services that may be of interest to you.

By signing this Policy and Procedures form, I, the undersigned client, acknowledge that I have read and understand all the terms and information contained herein; that I have received a copy of the Notice of Privacy Practices and that ample opportunity has been offered to me to ask questions and seek clarification.
Client/ Parent: 

Date: 
 
 
As witnessed by:   Date: