Rev: Dec. 2019 Minor Page 1 of 10

Date:

Minor Intake Form

The information requested on this form will be kept confidential. Please fill out the form as completely as possible.

Who referred client? Why did they refer client?

Why did you choose WTCG over other options?

What would you like to see happen as a result of counseling?

Did something happen to prompt you to seek help now, versus when the problem first began?

Is there pending / expected court involvement: custody, placement, parental rights, CPS? Y N

Is the client seeking disability due to their current mental/emotional health? Y N

Is the client seeking counseling due to a court order or criminal charges? Y N

Client Information

Last Name First Name Middle Initial

Birth Date / / Social Security Number ------------------------

Street Address Apt #

City State Zip Home phone

Parent/Guardian’s Cell phone Email

May we: Call Leave a message Text None Prefer: Cell Home

Gender Sexual Orientation Do you identify as transgender? Male Straight/Heterosexual Yes Female Gay, Lesbian, or Queer No Non-binary/3rd gender Bisexual Prefer not to say

Prefer to self-describe Prefer to self-describe

Prefer not to say Prefer not to say

Relationship status: Single Significant other Cohabitating Engaged Married

Separated Divorced Widowed

If married, how long? If divorced/widowed, when?

Racial/Ethnic identity: African American Asian American Hispanic/Latino Native American

Pacific Islander White/Caucasian Other

Emergency Contact: Name Contact number

Relationship to the client

Rev: Dec. 2019 Minor Page 2 of 10

Military dependent? Y N

Education: Current grade School Problems at school? Y N

If yes, please explain

What services does child receive from school?

Employment: Full-Time Part-Time Student

Employer

What type of work do you do?

Family Parents: Married Cohabitating Never Married Separated Divorced

Mother Full Custody Joint Custody No Rights Other

Father Full Custody Joint Custody No Rights Other

If other, please explain:

Is there a legal document outlining custody? Y N (copy required prior to client being seen)

Is the minor in the care of a guardian or conservator? Y N If yes, who?

What is this person’s relationship to the child?

Is there a legal document detailing this? Y N (copy required prior to client being seen)

Siblings: How many? I am the: Oldest In the Middle Youngest Only Child

Sibling Ages

List everyone living in the home with the client (name & relationship)

What are the most significant events in clients’ life?

Has the client or anyone in the client’s family experienced abuse or neglect? Y N

Is the client currently experiencing abuse or neglect? Y N

Is there a history of CPS involvement? Y N If yes, please explain

Religion/Denominational preference Congregation (if any)

Rev: Dec. 2019 Minor Page 3 of 10

Check all that the client is experiencing

Thoughts of suicide

Thoughts of death

Plans to harm self

Thoughts of harming others

Plans to harming others

Self-injury

Loss of meaning in life

Loss of hope

Depression

Decreased pleasure

Lack of activities

Isolating/withdrawn

Decreased energy/fatigue

Change in appetite

Significant weight change

Feelings of worthlessness

Grief

Loneliness

Guilt feelings

Anxiety

Excessive worry

Panic Attacks

Chronic fear

Irrational fears

Problems due to abuse/trauma

Stress

Obsessions

compulsions

Phobias

Feel like I’m losing control

Restlessness

Muscle tension

Problems with sleep

Problems with concentration

Problems with memory

Avoid open spaces

Behavioral problems

ADHD

Rage

Anger

Irritability

Relationship to significant other

Relationship to parents

Relationship to children

Sexual problems

Sexual orientation

Gender identity issues

Conflicts at work

Problems in school

Loss of faith in God

Religious doubts

Substance use problems

Hallucinations

Delusions

Easily distracted

Other/Explain below

What else is client experiencing at this time?

Mental Health

Has the client experienced mental health problems before? Y N If yes, explain

Does the client have a family history of mental health problems? Y N

Has the client ever received outpatient treatment (counseling, therapy, psychiatrist) for mental health issues?

Y N If yes, when and where?

Has the client ever been hospitalized or received inpatient treatment for mental health issues? Y N If yes,

when and where?

Rev: Dec. 2019 Minor Page 4 of 10

Self-Harm

Has the client ever attempted suicide? Y N If yes, number of attempts

Has the client ever lost someone they care about to suicide? Y N

If yes, who and when?

Substance Use History

Does the client drink alcohol? Y N On average, how many drinks do you have? per quantity & type day/week/month

Does the client use drugs (illegal drugs, recreational drugs, drugs not prescribed to client or used in excess of how

they are prescribed)? Y N If yes, which ones?

How often? per IV drug use? Y N quantity & drug day/week/month

Has the client ever been treated (counseling, therapy, psychiatrist, medication) for a drug or alcohol problem?

Y N If yes, when and where?

Completed successfully? Y N

Has the client ever received inpatient treatment (hospital, detox, or rehab) for a drug or alcohol problem?

Y N If yes, when and where?

Completed successfully? Y N

Medical History of Client

Pediatrician Date of last medical examination?

List any physical illness or symptoms the client is having at this time

List major surgeries or illnesses

List current medications (include dosages and physician prescribing)

Custody or guardianship paperwork is required (if applicable) prior to a minor client being seen for services.

Acknowledgement

The information written on this form is accurate, to the best of my knowledge.

Signature of Parent / Guardian / Client Date

Rev: Dec. 2019 Minor Page 5 of 10

Appointment Reminder Preference

Client Name:

West Texas Counseling & Guidance utilizes a contracted service to provide automated reminders of your next appointment 24 – 48 hours in advance as a courtesy reminder. Please choose a reminder option.

Yes, I would appreciate a phone reminder. Please call me prior to my appointment at . I understand that if others have access to this number, confidentiality cannot be ensured.

Yes, I would appreciate a text reminder. Please text me prior to my appointment at . I understand that if others have access to this number, confidentiality cannot be ensured.

No, I would prefer not to be reminded of appointments and will keep up with them myself.

Signature of Parent / Guardian / Client Date Relationship to client

Signature of WTCG Staff Date

Rev: Dec. 2019 Minor Page 6 of 10

No Shows, Cancellations, & Payment for Services Client Name:

When you schedule an appointment with our staff, West Texas Counseling & Guidance reserves that time just for you. If

you are not going to attend your scheduled appointment, we would like to give another client the opportunity to take that

opening. It affects our funding, our ability to budget our staff, and staff salaries when there are missed appointments. That

is why we require 24-hour advance notification of cancellation. Leaving a message with our answering service is fine, even

on weekends. The time you called will be posted with the message. If you do not give 24 hours’ notice before cancelling

your appointment, do not show for your appointment, and/or are more than 15 minutes late more than two times in a

three-month period, you may be asked to schedule with another therapist or moved to the WTCG wait list for services.

Clients may also be charged a $50 missed fee prior to being seen again. If you are being seen for reduced fee and pay less

than $50 per session, the fee will be your usual session charge. Those seen without a session fee will be charged $5 per

missed session. Clients with certain insurances cannot be billed the missed appointment fee - Medicaid, Employee Assistance Programs (EAP), or some private insurances. We appreciate the courtesy you extend to us by honoring this agreement. Please note that we cannot bill your insurance company for missed sessions or for late cancellations. All clients scheduled to be seen in the appointment must be present in order for the appointment to be considered kept (both partners for couples counseling, etc.) Certain insurances may not reimburse for some services offered at WTCG; in the event that insurance does not reimburse for a service provided and the client does not qualify for one of several client assistance programs at WTCG, the client will be held responsible for payment for that service.

Counselor Discretion: The counselor may choose to continue to see the client without requiring same- day appointments. The counselor may also waive the $50 fee. Weather Related: Missed appointments due to dangerous weather will not count as a late cancellation. Due to the counselors maintaining a set schedule:

• If you are 15 minutes late for 60-minute appointment, you may not be seen.

• If you are 10 minutes late for a 45-minute appointment, you may not be seen.

• If you are 5 minutes late for a 30-minute appointment, you may not be seen.

By signing this agreement, I acknowledge my understanding of all the policies listed above. I accept and agree to all of the above terms during the course of my treatment at West Texas Counseling & Guidance.

_________________________________ _______________ __________________________ Signature of Parent / Guardian / Client Date Relationship to client

Signature of WTCG Staff Date

Rev: Dec. 2019 Minor Page 7 of 10

Informed Consent for Psychotherapy/Counseling & Receipt of Privacy Practices

Client Name:

I have been provided with a printed copy of the Explanation of Psychotherapy/Counseling

Services and Notice of Privacy Practices packet. In addition, the

therapist/counselor/clinical social worker has provided a verbal explanation of

psychotherapy/counseling/clinical social work services and privacy practices, to include

exceptions to confidentiality. I have been afforded an opportunity to review the

Explanation of Psychotherapy/Counseling Services and Notice of Privacy Practices packet,

other pertinent information, and to ask questions. All questions have been answered to

my satisfaction.

I am making an informed decision, free of any coercion, on behalf of the client to engage

in psychotherapeutic/counseling/clinical social work services. It is my right to terminate

these services at any point.

Signature of Parent / Guardian / Client Date Relationship to client

Signature of WTCG Staff Date

Date:

Military Program Eligibility Form

The information requested on this form will be used to help determine eligibility for services provided to U.S. military service members and their families. Please fill out the form as completely as possible.

Client’s First Name Last Name Middle Initial

1. Has the client ever served in the U.S. Military? Y N What is your current military status? Active Duty Prior Service National Guard/Reserves

Dates of service: from to

2. Is the client related to any of the following who have ever served/or are currently in the U.S. military? Y N

Spouse Fiancé Boyfriend/girlfriend Son/daughter Sibling Parent Grandparent

If you answered no to 1 or 2, you do not have to continue this form.

3. If you answered yes to 2, please answer the following:

Name of service member:

Dates of service: from to

Individuals requesting services and claiming eligibility without documentation will be granted eligibility for 3 sessions. This allows the veteran or family member to acquire the DD 214 (per the National Archives, 92% of requests for DD214 receive a response within 10 days), plus, additional time to obtain necessary documentation and other ID to establish eligibility.

Eligibility of military or dependent status established by following documentation

Each individual seeking services needs to verify eligibility as either a service member or a qualified family member. Please see example of documents below needed to verify eligibility. If individual is a family member, eligibility of the service member and the relationship to the service member is required by our grant funding this program.

Veterans

DD Form 214, Certificate of Release or Discharge from Active Duty NGB-22, National Guard Report of Separation and Record of Service NA Form 13038, Certification of Military Service Department of Veterans Affairs (VA) official letter or disability letter E-Benefits summary letter Uniform Services Identification Card State of Texas Issued Driver License with Veteran designation Certificate verifying Active Duty Status from Department of Defense Manpower Data

Center (ONLY – currently serving active duty) Tricare, Triwest, or CHAMP VA insurance

Family Member

Uniform Services Identification Card Marriage Certificate - Must have one of the above with sponsors’ proof of Veteran

Status Birth Certificate - Must have one of the above with sponsors’ proof of Veteran Status Adoption Certificate - Must have one of the above with sponsors’ proof of Veteran

Status Tricare, Triwest, or CHAMP VA insurance

Surviving Spouse

Uniform Services Identification Card Marriage Certificate - Must have one of the above with sponsors’ proof of Veteran

Status Death Certificate - Must have one of the above with sponsors’ proof of Veteran Status Tricare, Triwest, or CHAMP VA insurance

Copy of eligibility documents provided and included in chart Alert has been created in chart stating “needs military documentation”.

Staff Member ________________________________________ Date _________

West Texas Counseling & Guidance HHS00032900002

HHSC Texas Veterans + Family Alliance (TV+FA) Grant Program Survey Please check all t hat apply:

1. What services did you receive?

Counseling or Therapy (with physician/licensed counselor/clinician)

Individual Support Services (employment, t ransportation, financial, education, housing)

Peer Support (veteran peers, support group)

Referral Assistance (case management, benefits)

Physical Health & Wellness (Yoga, meditat ion, physical activity)

Other (Please describe): _______________________________________________________________

2. Which of the following identifies you? Veteran Family member

3. Which branch of service did the veteran serve?

Air Force Army Coast Guard Marine Corps Navy .

4. Which military service did the veteran serve?

Active Guard Reserve 5. When did the veteran serve in the U.S. Armed Forces?

1947 - 1950

1951 - 1955

1956 - 1964

1965 - 1975

1976 - 1990

1991 - 2001

2002 or later

6. Did the veteran serve in a war or area of armed conflict?

Yes No

7. Do you feel better after receiving services at this program or organization?

Yes No

8. Services helped me and my family: Circle all that apply.

Sleep better Get or keep a place to live

Improve family relat ionships

Get or keep a job

Improve my moods and emotions

Do better in school

Improve relat ionships with friends

Have more people/places in the community for support

Have more places in the community where I can help others

Other (Please describe):

West Texas Counseling & Guidance HHS00032900002

9. Which were the most important areas for you to experience improvement? Circle all that apply.

Sleep better Get or keep a place to live

Improve family relat ionships

Get or keep a job

Improve my moods and emotions

Do better in school

Improve relat ionships with friends

Have more people/places in the community for support

Have more places in the community where I can help others

Other (Please describe):

10. How satisfied were you with the service you received?

Not sat isfied 1 2 3 4 5 Very Sat isfied 11. How satisfied were you with the process of finding and accessing these services?

Not sat isfied 1 2 3 4 5 Very sat isfied

12. What else would you like us to know? Please give us your feedback.

3

INFORMED CONSENT for Telehealth/TeleCounseling

Telehealth/Telecounseling refers to diagnosis, consultation, billing, client education, and professional

education/training delivered via electronic technology. This allows clinicians at West Texas Counseling &

Guidance to connect with clients using interactive video/audio data communication. One benefit is that the

client and clinician can engage in services without physically being in the same location. This can be beneficial

if the client moves to a different location or is unable to meet in person for appointments. It can also serve as

an opportunity for treatment that may not be accessible for the client in their location.

Technology related Issues

I understand that I will need to download an application/software and ensure good broadband Internet connection or a smart phone device with solid cellular connection for these services. I am solely responsible for any cost to obtain necessary equipment, accessories, or software to take part in telecounseling services.

I understand that in the case of technology failure, I will attempt to re-establish connection with my

therapist within my allotted appointment time. If I am unable to establish the connection, I will contact WTCG to reschedule my appointment or to coordinate alternative methods for treatment.

Risks to Confidentiality

I am expected to participate in my telecounseling sessions from a safe, confidential location that will ensure privacy and minimize noise/ distractions. I will provide my location at each session and announce any/all other individuals whom are present or within ear shot of sessions. I further understand that my sessions may be deemed inappropriate to continue by the therapist due to any distractions or issues with confidentiality that are present.

I understand the risks unique and specific to Telecounseling services, despite reasonable efforts by WTCG,

which may include potential of therapy sessions and communication becoming distorted, disrupted by technology failures; or sessions becoming accessible to unauthorized persons.

Access to Services

I understand telecounseling services will not be provided to me if I am outside the State of Texas.

I understand scheduling appointments is based on my clinician’s working business hours. Telecounseling appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. If I am in a state of emergency or crisis, I will contact WTCG to schedule a next available crisis appointment, if within business hours (M-F, 8a-5p). I have also been provided a copy of additional crisis contacts if WTCG is not accessible or is closed located in the Explanation of Psychotherapy/Counseling Services. I understand that prior to discharge or termination of services for telecounseling, I will comply with a final telecounseling session with my therapist.

Fees

The same fee rates will apply for telecounseling as apply for in-person counseling sessions. However,

insurance or other managed care providers may not cover sessions that are conducted via telecommunication.

If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic

psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your

insurance company prior to our engaging in telepsychology sessions in order to determine whether these

sessions will be covered.

Crisis Management Plan: Furthermore, I understand if deemed necessary, my therapist may request a Welfare Check to be completed, contact local authorities and/or 911. Lastly, my therapist may also make recommendations for alternative treatment or refer me for a next available crisis appointment with WTCG staff. I understand that in the event of an emergency/crisis, or if the therapist is unable to clearly determine factors to ensure my own safety or that of someone else in the middle of my session, my therapist has the right to contact the following individuals for additional assistance:

1) Personal Contact:___________________________________________________________________

Phone Number(s):___________________________________________________________________

2) Personal Contact: ___________________________________________________________________

Phone Number(s):___________________________________________________________________

3) Professional Contact:________________________________________________________________

Phone Number(s):___________________________________________________________________

I, _________________________________________________, (name of client) consent to participate in telecounseling services at West Texas Counseling & Guidance and agree to the following policies. I have discussed the policies with my therapist and have had the opportunity to ask any questions I may have in regard to telecounseling services prior to participation.

_______________________________________ ___________________

Client Signature DATE

_______________________________________ ___________________

Signature of WTCG Staff DATE

Client initiating/requesting TeleCounseling Sessions with their assigned therapist

“WTCG can now provide additional services allowing you to participate in sessions via TeleCounseling with your

therapist. Telecounseling will allow you to participate from the comfort of your own home or another

comfortable environment of your choice. Telecounseling can be set up by using a cell phone, computer or

tablet; you just need to ensure the device is reliable and has camera and speaker accessibility.”

The steps are as follows:

1. Type "WTCG.Doxy.Me” in a search browser

2. Click on the drop down menu under you clinician's room name

3. Search for name provided to you for your assigned therapist in the drop down menu and click enter room.

4. Enter your own Name to allow your therapist to see you in waiting room, then click check in

5. If prompted, allow camera and audio access to be able to communicate with your therapist.

6. Please wait, allow your therapist time to transition from one appointment to the other, this may take a few mins. If your therapist hasn’t come on virtually to join the session within 15 minutes of your scheduled appointment, please contact WTCG office at 325-944-2561.

***These instructions will be used for follow up sessions as well***