Client Agreement

First Name:

Middle Name:

Last Name:

Today's Date:

Gender:

Birth Date:

Race:

Veteran:

Education Level:

Home Address (Street Number, Street Name, City, State, ZIP):

Phone Number:

Email Address:

Emergency Contact:

Emergency Contact Phone Number:

Emergency Contact Relationship To You:

How did you find us?:

Do you work?:

Employer Business Name:

Your Business Title:

COUNSELING HISTORY:

Have you had previous counseling?:

Dates you attended counseling:

Counselor Names and reasons for counseling:

Reason for the requested appointment:

List any concerns you have:

List any medications you are currently taking AND the reason for each:

Have you ever thought about or attempted suicide:

What dates and at what ages did you attempt suicide:

Has anyone in your family, or friends committed, or attempted suicide:

If yes who committed suicide:

What are your positive attributes or characteristics:

PERSONAL HISTORY:

What is your LEGAL relationship status?:

Length of time in latest relationship:

Name of Your Physician:

Physician City and State:

Date of Last Physician Visit:

Reason for last Physician visit:

List current or past health issues you are concerned about:

List the Dates and Reasons for any Hospitalizations:

List any death or losses significant to you - Who, How, When:

Alcohol and Drug Use:

(Please Be Honest. This is Confidential) For purposes of these questions, 1 drink is considered either: 12 ounces of regular beer 5 ounces of wine 1.5 ounces of distilled spirits

Do you drink alcohol:

How old were you when you had your first drink of Alcohol:

For how long have you been drinking at least weekly:

How often did you have a drink containing alcohol in the past year:

How many drinks did you have on a typical day when you were drinking in the past year:

How often did you have six or more drinks on one occasion in the past year:

Substance Use:

List the specific substance names, how often (hourly, daily, weekly, monthly, annually) and in what quantities have you used the following substances

Marijuana (natural or synthetic):

Methamphetamines:

Cocaine:

Tranquilizers:

PCP:

Hallucinogenic Drugs (LSD, Mushrooms, etc.):

Narcotics (Heroine, Fentanyl, etc.):

Spice:

Ecstacy:

Kratom:

Delta 8, 9 or 10:

Other:

Please explain any trauma you have experienced in your life:

Name of Mother and if Living or Deceased:

Describe Relationship with Mother:

Name of Father and if Living or Deceased:

Describe relationship with Father:

List Sibling Names and Ages and describe your Relationship with them:

Are you parents still together?:

Date of Divorce or Separation:

With what Religious Faith do you associate yourself?:

How often do you attend in person meetings for your faith?:

List any other concerns you may have:

Counseling Agreement:

Life Patterns Ministry PO Box 328, Holly Springs, GA 30142-0006 Phone: 678-459-2437 pennyhaynes@rpmministries.com www.PennyHaynes.com Counseling Services Agreement Ensuring Fully Informed Consent for Counseling and Introducing How We Do Therapy Welcome to Life Patterns Ministry. We appreciate the opportunity to serve you. This document answers questions which clients often ask about counseling. We believe our work will be most helpful to you when you have a clear idea of what we are trying to do. This document also contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us. A primary commitment of Life Patterns Ministry is to provide you with Biblically Christian and Clinically Proven counseling services. Life Patterns Ministry, hereafter LPM, is committed to your right of information regarding: · Standards of Competent Service · Services the counselor will provide · Goals of the therapeutic relationship · Risks and benefits of therapeutic procedures · Policies and Procedures · Behavior expected of the client · Physical evaluation · Financial considerations · Payment arrangements · Electronic & Phone Sessions · Emergency Sessions · Non-discrimination · Sexual conduct · Contact information · Qualifications, Credentials, and Associations · Confidentiality · Electronic Communication · You are not required to be recorded or have any obligation from being recorded. · You can withdraw permission to record at any time. · Recording is for the purpose of insuring excellent client care and the training of therapists of Life Patterns Ministry. · All information presented in a recorded session will remain confidential. · Any concerns you may have regarding the recording process can be addressed at any time with your counselor. Minors: If you are under seventeen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is LPM’s policy to request an agreement from parents that they agree to give up access to your records. If they agree, your counselor will provide them only with general information about your work together, unless he or she feels there is a high risk that you will seriously harm yourself or someone else. In this case, your counselor will notify them of his or her concern. Your counselor may also provide them with a summary of your treatment when it is complete. Before giving them any information, your counselor will discuss the matter with you, if possible, and do his or her best to handle any objections you may have with what your counselor is prepared to discuss. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. Your counselor will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and we are not attorneys. Consent When you have read this document, have discussed it with your therapist and received a copy of both this document and the Notice of Privacy Practices, please sign the Informed Consent Signature Form. Your signature indicates you have read and been given a copy of the Life Patterns Ministry Agreement and understand the conditions as read and agree to receive counseling under these conditions. LPM COUNSELOR BRIEF VITA ADDENDUM Penny S. Haynes, CADC II, CAMSI, MATS, CCTP, Licensed Pastoral Counselor Certification: #1348 – Alcohol and Drug Abuse Certification Board of Georgia, Certified Alcohol and Drug Counselor II, Atlanta, GA (IC & RC Reciprocity in 48 states) Certification: Addiction Counselor USA, Atlanta, GA, Certified Anger Management Specialist I Licensure: #19322 - National Christian Counselors Association, Licensed Pastoral Counselor, Sarasota, FL Certification: Arno Profile System (APS) Temperament Theory/Therapy, National Christian Counselors Association, Sarasota, FL Association: Professional Clinical Member, National Christian Counselors Association, Sarasota, FL Education: B.A. in Religion, Furman University, Greenville, SC Theological: Teamwork Bible College, Ministerial Training Notice of Privacy Practices This notice describes how psychological and clinical health care information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Uses and Disclosures for Treatment, Payment and Health Care Operations Life Patterns Ministry (LPM) may use or disclose your protected health information (PHI) for treatment, payment, and health care operations for the purposes within your written authorization. To help clarify these terms, here are some definitions: · The term “PHI” refers to information in your health record that could identify you. · “Treatment, Payment and Health Care Operations” o Treatment is when we provide, coordinate, or manage your mental health care and related services. An example would be when your counselor consults with another health care provider, such as your family physician or another counselor. o Payment is when LPM is reimbursed for services provided to you. Examples of payment related disclosures are when information are disclosed to entities attempting to collect a debt. o Health Care Operations are activities that relate to the operation of LPM’s office practices. Examples are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management, scheduling and care coordination. “Use” applies to actions within LPM such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. “Disclosure” applies to activities outside of LPM such as releasing, transferring, or providing access to information about you to other parties. “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form. Other uses and Disclosures Requiring Authorization LPM may disclose PHI for purposes outside of regular treatment, payment, or health care operation only when you sign a specific authorization for that purpose. An “authorization” is written permission above and beyond the general consent that permits the normal PHI disclosures. An example would be if an attorney or one of your family members wanted to know. If LPM revises its policies and procedures, LPM will provide you with an updated notice at your next scheduled visit to your facilities or by mail. LPM will also post this notice in a public area in its office. LPM cannot guarantee the absolute confidentiality of electronic & phone sessions, as these are not in office sessions and utilize technology beyond the counseling center. Complaints If you are concerned that LPM has violated your privacy rights, or you disagree with a decision made about your access to records, you may file a formal complaint with LPM. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Information about filing such a complaint can be found online at: www.hhs.gov/ocr/privacyhowtofile.htm or the person listed above can provide you with the appropriate address upon request. Please note that you will not receive retaliation for filing a complaint with either LPM or the U.S. Department of Health and Human Services. Effective Date, Restrictions, and Changes to Privacy Policy This policy went into effect on November 1, 2017. LPM reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that LPM maintains. LPM will provide you with a revised notice at the time of your next visit to our facilities or by mail. ---------------------------------------------------------- I have read the privacy practices statement and have received a copy. I have reviewed the Life Patterns Ministry Counseling Services Agreement and have received of copy for my personal record. By signing below, I am verifying that the above information is accurate.

Client Signature:

Clear

Name of Legal Guardian:

Signature of Legal Guardian (if Client is under 18 years of age):

Clear

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Client Agreement