Client Information Sheet

Instructions: Please complete all of the following questions accurately. This information
will be helpful in serving your needs. This information is confidential. 

Client name: _____________________________________ Date: _________________
Address: ________________________________________________________________
City, State: __________________________________________ Zip: ________________
Phone numbers with area code        Home: (      )___________________
Work: (     )_______________           Cell: (      )_________________

EMAIL ADDRESS:________________________________

Name of Insurance Company: ____________________   Deductible: ________________
ID#: ____________________			        # Sessions: _________________
Birth date: ________________			       Copay:  ___________________	        
Insurance Telephone Number: _______________   	        Prior Authorization:  ________ 

What kind of problem(s) brings you to Counseling? ____________________________________________________________________________________________________________________________________________________________________________________________________

What are your goals in Counseling?     	

Employer: _______________________________________________________________
Education: ______________________________________________________________
Marital/relationship status: _____________ Significant other? name: _______________
Significant other? age and sex: __________ How long together? ___________________
# of people in household: ____________________________________
How did you hear about me?___________________________________
Who shall we contact in case of emergency?
 Name: ______________________________________Phone (    )____________

In this box, IF different than above; please list the telephone number that you want us to use to when I need to contact you.  If you do not want us to leave a message on your answering machine, please tell us how you want us to reach you by phone:
I hereby consent for Elizabeth Polasek, M.A., L.M.H.C. to provide evaluation and treatment for me.  

_________________________________				________________________
Signature 							Date

Medical and Health History
					
List any allergies you have: _______________________________________ None_____
Primary Care Physician: _________________________
											
Date of your most recent physical examination and problem: ________________________________________________________________

Have you been in counseling before? 
Please list any specific therapeutic techniques that did not work for you?____________________________
______________________________________________________________________________________

Please list all current medications and dosages:
Name of Medication 			Dosage	  Prescribing Doctor		When did you start taking it?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list all current or past health problems, and any major operations:

List any substance abuse treatment or inpatient psychiatric treatment you have had, and the dates:_______________________________________________________________
								
Please indicate which of these substances you currently use:			
How often?
___Cigarettes  ___Alcohol   ___Pills not prescribed for me  ___Marijuana
Please indicate if you are having any of the following problems, or if you had them in the past:

Activities enjoy now:  ___________________________________________________________________________
Activities enjoyed in past ________________________________________________________________________

                   	         	NOW   IN PAST

Difficulty falling asleep or staying asleep 	  	 _____	_____	
Sleeping too much 	  						_____	_____                                                   Change in appetite, weight loss, or weight gain 	 		              _____	_____
Frequent crying 	 							_____	_____
Thoughts of killing or hurting myself 	  				_____	_____
Attempts to kill or hurt myself 	  					_____	_____
Problems concentrating 	  	  _____	_____
Problems remembering things 	  					_____	_____
Periods of daily sadness lasting more than two weeks	  		_____	_____
I feel tired almost every day 	  					_____	_____
Feeling worthless or guilty for no reason 					_____	_____
Loss of interest in favorite activities 
									_____	_____
Panic attacks or anxiety attacks 	  					_____	_____
                         							
									NOW	IN PAST
I startle easily 	  							_____	_____
Can't stop remembering upsetting past events 	  			_____	_____
Difficulty controlling my temper 	  					_____	_____
I physically hurt other people 						_____	_____  				     
I break things sometimes 	  						_____	_____
Frequent arguments with the people I live with 	  			_____	_____

I worry a lot 	 							 _____	_____
Little or no interest in sex 	 						 _____	_____
Feelings of unreality 	  						_____	_____
Made myself throw up in order to lose weight 	  			_____	_____
Used laxatives or exercised excessively to lose weight                    		_____	_____
I often feel like I am an outsider 	  	  _____    _____
Sexual problems 	  							_____	_____
Worry that something is wrong with my body	 	  _____    _____

I hear voices inside my head                                          	  		_____	_____
 Other (please list): ____________________________________________________________________________________________________________________________________________________________________________________________________

Relationship Information:							

Please give name of current spouse/significant other and length of relationship:
_______________________________ 
Previous marriages? _____________________________________

(Circle all that apply) 
Currently living with: alone spouse Significant other housemates
               children siblings parent(s)
Family members (Name) 
Wife __________________________________
Husband _______________________________
Child__________________________________
Child__________________________________
Child__________________________________
Important others _______________________________

CONFIDENTIALITY AND FILES
HIPAA (Health Insurance Portability and Accountability Act)
The laws governing confidentiality can be quite complex. The attached Notice explains some specific Patient Rights that you have under the HIPAA law.  We will maintain a Clinical Record file on your case, which is the property of Elizabeth Polasek Counseling. However, I am a mandated to report in few situations where I am required to disclose information to authorities. These situations are listed below.

Your signature on this agreement is written, advance consent for the following releases of information:
•	Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During consultations, your therapist makes every effort to avoid revealing the identity of patients. The other professionals are also legally bound to keep the information confidential. The therapist will note all consultations in your Clinical Record.

•	Your therapist may find it helpful to receive or exchange information with your primary care physician or other health and mental health professionals who are currently treating you. Your signature on this Agreement is written, advance consent for me to release information to these professionals.  A record of any disclosures will be kept in your Clinical Record.

_____ Check here if do NOT wish us to release any information to other mental health and health   professionals who are currently treating you.

There are some situations where Elizabeth Polasek, M.A., L.M.H.C. is required to disclose information without your consent or authorization:
•	If a client is clearly likely to seriously harm him/herself, we may be required to take action to prevent self-destruction.

•	If there is a clear risk that a client plans to seriously harm another person, we may have a duty to warn the potential victim; or disclose the risk to appropriate public authorities.

•	If a therapist suspects that abuse of a child or senior citizen may have taken place, the therapist is required to report the suspected abuse to the Department of Social and Health Services.

•	If the client is a minor younger that age 13, both parents have access to the minor client? complete Clinical Record, including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access.

•	If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client privilege law. I cannot provide any information without your (or your personal or legal representative?) written authorization. However, if a court orders or subpoenas Elizabeth Polasek, M.A., L.M.H.C.to disclose information, we are required by law to provide it. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

•	If a client files a complaint or lawsuit against Elizabeth Polasek, I may disclose relevant information regarding that patient in order to defend itself.

•	If a client files a worker? compensation claim, the client must sign an authorization so that Elizabeth Polasek, M.A., L.M.H.C. may release the information, records or reports relevant to the claim.

•	Elizabeth Polasek, M.A., L.M.H.C. may present disguised case material in seminars, classes, or scientific writings.  In this situation, all identifying information and Protected Health Information is removed, and client confidentiality and anonymity is maintained.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS, AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE OF PRIVACY PRACTICES DESCRIBED ABOVE.

__________________________________________________________            __________ 

Client or responsible party 						Date

                               

Psychotherapist-Client Services Agreement				

This form has three purposes. First, it tells you about my procedures and policies concerning important aspects of your psychotherapy. Please let me know if you have concerns about any of these policies. Your first visit will help me get a general understanding of your situation in order to determine how I might best help you. Because I want you to participate actively in planning your counseling, don? hesitate to ask questions. 

Psychotherapy is a way of talking through your problems in order to begin resolving them. You will need to take an active part in psychotherapy by working on and thinking about the things you talk about with your therapist. Psychotherapy has been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and feeling much less distressed. However, there are no guarantees of what you will experience, and at times a psychotherapy session may leave you with unhappy feelings. 

Second, this form is an Agreement between you and Elizabeth Polasek. You may revoke (cancel) this Agreement in writing at any time. That revocation will be binding on unless I have already relied on this Agreement to take action or if you have not paid your bill in full.

Finally, this form also contains information about a federal law that affects your privacy rights. This law, called HIPAA (Health Insurance Portability and Accountability Act), regulates the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that we give you a Notice of Privacy Practices (the Notice). The Notice, which is attached to this Agreement, explains HIPAA? application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Please take home the Notice and read it before your next session; you and your therapist can discuss any questions you may have about it next time.

APPOINTMENTS, HOURS 

Individual appointments last approximately 50  minutes and can be scheduled through me.  Please leave a message on 360-420-2654.  If you need to cancel an appointment, notify me at least 24 hours before the session, or you will be responsible for reimbursement for the time you reserved for appointment. However, if you call in advance to cancel an appointment because you are ill, there will be no charge.

Fees for Counseling and Financial Agreement

1.  PAYMENT ARRANGEMENT:
All cash payments or insurance co-pay fees are payable in full at the time of service.  Overdue accounts are charged interest at the rate of 10% per year.  Payment may be made in cash or by check. 
		
2.  COLLECTIONS PROCEDURES: 
Elizabeth Polasek, M.A., L.M.H.C. reserves the right to collect any unpaid balance due to it. Elizabeth Polasek may use a collection agency or take legal action to secure payment, as authorized by state or federal law, and the collections action will become a part of your credit record. Clients will be notified in writing before Elizabeth Polasek, M.A., L.M.H.C. Counseling takes action to collect.

I have read and understood the above fee agreement, and I agree to abide by its terms.

_____________________________________ _______________
Client or Responsible Party 				Date