date minor intake form · 2020-06-22 · for a service provided and the client does not qualify for...
TRANSCRIPT
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***