Download client intake packet

Journeys of Hope Counseling
Pamela Montgomery MA EMDR
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
Client Information Form
General Information
Full Name:. _______________________________________________________Date:_______________
Age: ____________________________ Date of Birth: ________________________________________
Street Address: _________________________City: _______________ State: _____ Zip Code: ________
Home Phone: (_______) ______________________
Cell Phone: (_______) _____________________
Email Address: ________________________________________________________________________
May I leave a message at these phone numbers and send mail to these addresses?: □ Yes □ No
Would you like to be added to the mailing list for my periodic e-newsletter?: □ Yes □ No
Emergency Contact
Name: __________________________________________________Relationship: __________________
Home Phone: (__________) ____________________ Mobile Phone: (_________) _________________
Referral
How did you hear about me?__________________ May I thank them for sharing my name?: □ Yes □ No
Medical Information
Are you currently receiving medical treatment: □ Yes □ No.
List relevant medical conditions, surgeries, traumas or treatments you have had: (Use back if necessary):
_____________________________________________________________________________________
Medications
List any current medications you are taking (Use back if necessary):
Medication: ____________________________ Dosage: ______________ Purpose: ________________
Medication: ____________________________ Dosage: ______________ Purpose: ________________
Are you taking these medication(s) according to your doctor’s recommendations: □ Yes □ No
Level of Distress
Indicate how distressed you are by placing an “X” on the scale below (1 = Very Little Distress; 10 =
Extreme Distress):
1
2
3
4
5
6
7
8
9
10
Are you currently experiencing any suicidal thoughts: □ Yes □ No
Have you experienced them in the past: □ Yes □ No
Have any of your friends or family ever committed or attempted suicide: □ Yes □ No
If yes, when and who: _________________________________________________________________
Previous Counseling
List any previous counseling, psychiatric treatment, or residential/in-patient care you have received (Use
back if necessary):
Therapist: _____________________________ Dates: ____________ Reason: _____________________
Therapist: _____________________________Dates: _____________ Reason: _____________________
Presenting Issues and Goals
Please describe why you are coming to counseling ____________________________________________
_____________________________________________________________________________________
Why have you decided to come for counseling now?: _________________________________________
_____________________________________________________________________________________
What do you hope to gain or change by coming for counseling?: ________________________________
_____________________________________________________________________________________
Terms of Service
I Understand that it is customary to pay for services when rendered. I accept full responsibility for
payment of any balance incurred for services. I further understand that without 24-Hour Notice of
Intention to Cancel, I will be charged the full appointment fee for service.
_______________________________________________________________ _____________________
Client Signature (parent or guardian of minor)
Date
Journeys of Hope
Pamela Montgomery MA
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
Counseling Policies
Appointments
Appointments are scheduled directly with me. In general, appointments are scheduled on a weekly or biweekly basis, but are also offered on an “as-needed” basis. If you must cancel an appointment, please do
so a full 24-hours in advance of the session. Missed or canceled appointments with less than 24 hours
notice will be charged at your usual fee (except in the infrequent instances of emergencies, or acts of
God).
Contacting Me
If you need to speak with me between your regularly scheduled sessions, please feel free to call my
confidential voicemail at 719-235-2686 or email me at pam@pammontgomery.com. If I am not available,
leave a message and I will return your call or email as promptly as possible, usually within 24 hours. All
phone calls lasting more than 10 minutes will be charged to you on a prorated basis. I reserve the right to
answer lengthy emails in our sessions.
Emergencies
While I try to make myself reasonably available to my clients, there will be times when I am unavailable
or out of cell phone range. If you have an emergency situation and cannot reach me either call 911, call
the Pikes Peak Crisis Hotline at 719-635-7000 or go to a local emergency room.
Fee Information
The basic fee for individual sessions is $90 per 50-minute session. Group therapy fees are dependent on
the specific group. These fees for counseling services are based on customary and reasonable fee profiles
for this area. Payment is expected at the time service is rendered. At this time, I accept cash, check or
credit card/debit payments. Make your check payable to “Pamela Montgomery”. There is a standard $25
fee for all checks returned due to insufficient funds. Credit or debit card payments can be made via Paypal
– payable to montygal@gmail.com. Paypal payments require a $2 service fee. Therefore, the regular fee
would be $92.
If you should encounter financial difficulties at any time during counseling, please discuss this
with me promptly. In the event you get two sessions behind in paying your fee, another appointment will
not be made until you and I agree on how you will pay past and future fees.
Referrals
Finally, the work that I do is highly based on word of mouth referrals. I am always thankful and
appreciative of all referrals from my clients. Please let me know if you would like to have cards/brochures
for anyone that you believe could benefit from my services. Thank you.
I acknowledge and agree to Journeys of Hope and Pamela Montgomery’s policies.
_______________________________________________________ _____________________
Client Signature (parent or guardian of minor)
Date
Journeys of Hope
Pamela Montgomery MA
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
Disclosure Statement
RETAIN THIS COPY FOR YOUR RECORDS
Pamela Montgomery MA EMDR received her Master’s Degree in Counseling at Colorado Christian
University in December of 2008 and is currently working toward licensure under the supervision of
Arnold Trillet LPC NCC CSAT. In 2009, I received certification in the use of Eye-movement
Desensitization and Reprocessing (EMDR) from the EMDR Institute. At this time, I am an unlicensed
psychotherapist registered in the Colorado Unlicensed Psychotherapist Database and am a member of the
American Counseling Association and the American Association of Christian Counselors.
REGULATION OF PSYCHOTHERAPISTS
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental
Health Licensing Section of the Division of Registrations. The regulatory boards can be reached at 1560
Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. The regulatory requirements for mental
health professionals provide that a Licensed Clinical social worker, a Licensed Marriage and Family
therapist, and a Licensed Professional Counselor must hold a masters degree I their profession and have
two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in
psychology and have one year of post-doctorial supervision. A Licensed Social Worker must hold a
masters degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate,
and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the
process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAC I)
must be a high school graduate, and complete required training hours and 1000 hours of supervised
experience. A CAC II must complete additional required training hours and 2,000 hours of supervised
experience. A CAC III must have a bachelors degree in behavioral health, and complete additional
required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must
have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is
registered with the State Board of Registered Psychotherapists, is not licensed or certified.
CLIENT RIGHTS AND IMPORTANT INFORMATION
a. You are entitled to receive information from me about my methods of therapy, the techniques I use, and
the duration of your therapy. Please ask if you would like to receive this information. My fee is $90 per
hour for counseling.
b. You can seek a second opinion from another therapist or terminate therapy at any time.
c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never
appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies.
d. Generally speaking, information provided by and to a client in a professional relationship with a
psychotherapist is legally confidential, and the therapist cannot disclose the information without the
client’s consent. There are several exceptions to confidentiality which include:
(1)
I am required to report any suspected incident of child abuse or neglect to law
enforcement;
(2) I am required to report any threat of imminent physical harm by a client to law enforcement
and to the person(s) threatened;
(3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to
self or to others, or who is gravely disabled, as a result of a mental disorder;
(4) I am required to report any suspected threat to national security to federal officials; and
(5) I may be required by Court Order to disclose treatment information.
e. Under Colorado law, C.R.S. §14-10-123.8, parents have the right to access mental health treatment
information concerning their minor children, unless the court has restricted access to such information. If
you request treatment information from me, I may provide you with a treatment summary, in compliance
with Colorado law and HIPAA Standards.
DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION
If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations
to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not
to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and
you agree not to request that I write any reports to the court or to your attorney, making recommendations
concerning custody. The court can appoint professionals, who have no prior relationship with family
members, to conduct an investigation or evaluation and to make recommendations to the court concerning
parental responsibilities or parenting time in the best interests of the family’s children.
If you have any questions or would like additional information, please feel free to ask.
I have read the preceding information and understand my rights as a client. I also acknowledge that I have
received a copy of this Disclosure Statement
__________________________________________________________Date_______________________
Client signature
__________________________________________________________Date_______________________
Pamela M. Montgomery, counselor
Journeys of Hope
Pamela Montgomery MA
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
Disclosure Statement
RETURN THIS COPY TO YOUR THERAPIST
Pamela Montgomery MA EMDR received her Master’s Degree in Counseling at Colorado Christian
University in December of 2008 and is currently working toward licensure under the supervision of
Arnold Trillet LPC NCC CSAT. In 2009, I received certification in the use of Eye-movement
Desensitization and Reprocessing (EMDR) from the EMDR Institute. At this time, I am an unlicensed
psychotherapist registered in the Colorado Unlicensed Psychotherapist Database and am a member of the
American Counseling Association and the American Association of Christian Counselors.
REGULATION OF PSYCHOTHERAPISTS
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental
Health Licensing Section of the Division of Registrations. The regulatory boards can be reached at 1560
Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. The regulatory requirements for mental
health professionals provide that a Licensed Clinical social worker, a Licensed Marriage and Family
therapist, and a Licensed Professional Counselor must hold a masters degree I their profession and have
two years of post-masters supervision. A Licensed Psychologist must hold a doctorate degree in
psychology and have one year of post-doctorial supervision. A Licensed Social Worker must hold a
masters degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate,
and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the
process of completing the required supervision for licensure. A Certified Addiction Counselor I (CAC I)
must be a high school graduate, and complete required training hours and 1000 hours of supervised
experience. A CAC II must complete additional required training hours and 2,000 hours of supervised
experience. A CAC III must have a bachelors degree in behavioral health, and complete additional
required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must
have a clinical masters degree and meet the CAC III requirements. A Registered Psychotherapist is
registered with the State Board of Registered Psychotherapists, is not licensed or certified.
CLIENT RIGHTS AND IMPORTANT INFORMATION
a. You are entitled to receive information from me about my methods of therapy, the techniques I use, and
the duration of your therapy. Please ask if you would like to receive this information. My fee is $90 per
hour for counseling.
b. You can seek a second opinion from another therapist or terminate therapy at any time.
c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never
appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies.
d. Generally speaking, information provided by and to a client in a professional relationship with a
psychotherapist is legally confidential, and the therapist cannot disclose the information without the
client’s consent. There are several exceptions to confidentiality which include:
(2)
I am required to report any suspected incident of child abuse or neglect to law
enforcement;
(2) I am required to report any threat of imminent physical harm by a client to law enforcement
and to the person(s) threatened;
(3) I am required to initiate a mental health evaluation of a client who is imminently dangerous to
self or to others, or who is gravely disabled, as a result of a mental disorder;
(4) I am required to report any suspected threat to national security to federal officials; and
(5) I may be required by Court Order to disclose treatment information.
e. Under Colorado law, C.R.S. §14-10-123.8, parents have the right to access mental health treatment
information concerning their minor children, unless the court has restricted access to such information. If
you request treatment information from me, I may provide you with a treatment summary, in compliance
with Colorado law and HIPAA Standards.
DISCLOSURE REGARDING DIVORCE AND CUSTODY LITIGATION
If you are involved in divorce or custody litigation, my role as a therapist is not to make recommendations
to the court concerning custody or parenting issues. By signing this Disclosure Statement, you agree not
to subpoena me to court for testimony or for disclosure of treatment information in such litigation; and
you agree not to request that I write any reports to the court or to your attorney, making recommendations
concerning custody. The court can appoint professionals, who have no prior relationship with family
members, to conduct an investigation or evaluation and to make recommendations to the court concerning
parental responsibilities or parenting time in the best interests of the family’s children.
If you have any questions or would like additional information, please feel free to ask.
I have read the preceding information and understand my rights as a client. I also acknowledge that I have
received a copy of this Disclosure Statement
__________________________________________________________Date_______________________
Client signature
__________________________________________________________Date_______________________
Pamela M. Montgomery, counselor
Journeys of Hope
Pamela Montgomery MA
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
HIPPA Notice
(retain this form for your records)
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records
and other individually identifiable health information (“Protected Health Information”) used or disclosed
to me in any form (whether electronically, on paper, or orally) be kept confidential. This federal law gives
you, the patient, significant new rights to understand and control how your health information is used.
HIPAA provides penalties to covered entities that misuse personal health information. As required by
HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health
information and how I may use and disclose your health information.
Without specific written authorization, I am permitted to use and disclose your health care records for the
purposes of treatment, payment, and health care operations.



Treatment means providing, coordinating, or managing health care and related services
by one or more heath care providers. Examples of treatment would include
psychotherapy, medication management, etc.
Payment means such activities as obtaining reimbursement for services, confirming
coverage, billing or collection activities, and utilization review. An example of this
would be billing your insurance company for your services.
Heath Care Operations include the business aspects of running my practice, such as
conducting quality assessment and improvement activities, auditing functions, cost
management analysis, and customer service. An example would include a periodic
assessment of our documentation protocols, etc.
In addition, your confidential information may be used to remind you of an appointment (by phone or
mail) or provide you with information about treatment options or other health-related services. I will use
and disclose your Protected Health Information when I am required to do so by federal, state or local law.
I may disclose your Protected Health Information to public health authorities that are authorized by law to
collect information; to a health oversight agency for activities authorized by law included but not limited
to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding;
response to a discovery request, subpoena, or other lawful process by another party involved in the
dispute, but only if I have made an effort to inform you of the request or to obtain an order protecting the
information the party has requested. I may release your Protected Health Information to a medical
examiner or coroner to identify a deceased individual or to identify the cause of death. I may use and
disclose your Protected Health Information when necessary to reduce or prevent a serious threat to your
health and safety or the health and safety of another individual or the public. Under these circumstances,
I will only make disclosures to a person or organization able to help prevent the threat.
I am required by law to protect the privacy of your Protected Health Information and to abide by the
terms of the Notice of Privacy Practices. I will make and post revisions to the Notice of Privacy Practices
in accordance with the law. You may obtain a written copy of these changes by written request. Further, a
general summary of the HIPAA Privacy Rule may be obtained upon request also.
Your written authorization will be required for any other uses or disclosures. Should you choose to revoke
your authorization, you may do so only in writing. I will abide by your written request with the exception
of information I released upon obtaining the written authorization and releasing of information as required
by law.
You may contact the Privacy Officer in writing to invoke your following rights:




You may request in writing that I restrict using and disclosing your Protected Health
Information to family members and relatives, friends, or others you identify. I reserve
the right to deny this request.
You may request an amendment to your Protected Health Information.
You may request alternative means or locations in which you receive confidential
communications.
You may request an accounting of disclosures of Protected Health Information beyond
treatment, payment, and health care operations.
You may file a formal, written complaint with me at the address below or with the Department of Health
& Human Services, Office of Civil Rights, if you feel your privacy rights have been violated.
For more information regarding our Privacy Practices, please contact:
Pam Montgomery MA
Journeys of Hope
7025 Tall Oak Dr., Ste 100
Colorado Springs, CO 80919
(719) 235-2686
For more information about HIPAA or to file a complaint, please contact:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775 (Toll free)
Journeys of Hope
Pamela Montgomery MA
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
HIPPA Acknowledgement
I acknowledge that I have received from Pamela Montgomery MA a copy of the HIPPA
notice of privacy rights. This notice contains information concerning how confidential mental
health treatment information concerning me may be used and disclosed and how to obtain access
to this information.
_______________________________________________________
(Client signature)
Journeys of Hope
_____________
(Date)
Pamela Montgomery MA
7025 Tall Oak Dr., Ste 120
Colorado Springs, CO 80919
719-235-2686
Authorization for the Release of Information
FILL OUT ONLY AS REQUESTED BY YOUR THERAPIST
Re:_________________________________________________________Date of Birth:______________________
(Name of client)
This is to authorize: _____________________________________________________________________________
(Name of person or agency holding information)
_____________________________________________________________________________________________
(Address)
______________________________________________________________ ______________________________
(City, State, Zip Code)
(Phone Number)
to disclose and release any information for the individual named above to _________________________________
(Name of person receiving information)
_____________________________________________________________________________________________
(Address)
_____________________________________________________________ __________________________, who:
(City, State, Zip Code)
(Phone Number)
____ is authorized to discuss all matters pertinent to the ongoing evaluation and treatment of this client.
____ is not authorized to discuss all matters pertinent to the ongoing evaluation and treatment of this client.
Information requested:
____ Psychiatric/Psychological/Counseling Records
____ Social Welfare Data
____ Psychological Testing
____ Rehabilitation Records
____ Educational Records
____ Legal Information
____ Medical Records
____ Other_________________________
* I am aware that all information I hereby authorize to be obtained from this person or agency will be held
strictly confidential within the limits of the law and cannot be released by the recipient without my written
consent.
* I understand that this authorization will remain in effect for the period necessary to complete all transactions on
accounts related to services provided to me.
* I understand that unless otherwise limited by state or Federal laws or regulations, and except to the extent that
action has to be taken on my consent, I may withdraw this consent at any time.
_____________________________________ __________________________ _____________________________
Client’s or Parent’s/Guardian’s Signature
Date
Social Security Number
*******************************************************************************************
Use this space only if client withdraws consent.
________________________________________________ __________________________
Client’s or Parent’s/Guardian’s Signature
Date
Limits of the Therapy Relationship: What Clients Should Know
Psychotherapy is a professional service I can provide to you. Because of the nature of therapy, our
relationship has to be different from most relationships. It may differ in how long it lasts, in the topics we
discuss, or in the goals of our relationship. It must also be limited to the relationship of therapist and
client only. If we were to interact in any other ways, we would then have a “dual relationship,” which
would not be right and may not be legal. The different therapy professions have rules against such
relationships to protect us both. I want to explain why having a dual relationship is not a good idea.
Dual relationships can set up conflicts between my own (the therapist’s) interests and your (the client’s)
best interests, and then your interests might not be put first. In order to offer all my clients the best care,
my judgment needs to be unselfish and professional.
Because I am your therapist, dual relationships like these are improper:
• I cannot be your supervisor, teacher, or evaluator.
• I cannot be a therapist to my own relatives, friends (or the relatives of friends), people I know
socially, or business contacts.
• I cannot provide therapy to people I used to know socially, or to former business contacts.
• I cannot have any other kind of business relationship with you besides the therapy itself. For example,
I cannot employ you, lend to or borrow from you, or trade or barter your services (things
like tutoring, repairing, child care, etc.) or goods for therapy.
• I cannot give legal, medical, financial, or any other type of professional advice.
• I cannot have any kind of romantic or sexual relationship with a former or current client, or any other
people close to a client.
There are important differences between therapy and friendship. Even though our therapeutic relationship
may be very strong, it is still different than friendship. Friends may see you only from their personal
viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that
they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do
not usually follow up on their advice to see whether it was useful. They may need to have you do what
they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps
you learn how to solve problems better and make better decisions. A therapist’s responses to your
situation are based on tested theories and methods of change. You should also know that therapists are
required to keep the identity of their clients secret. Therefore, unless you approach me first, I may not
recognize you in a public setting for the purpose of protecting your confidentiality. Lastly, when our
therapy is completed, I will not be able to be a friend to you like your other friends.
In sum, my duty as therapist is to care for you and my other clients, but only in the professional role of
therapist.
HANDOUT 1. Patient handout on limits of the therapy relationship. From The Paper Office. Copyright 2003 byEdward L.
Zuckerman. Permission to photocopy this handout is granted to purchasers of this book for personal use only (see copyright
page for details).