Christina Unruh, MSW, LCSWA Initial Intake Packet

Transcription

1 Christina Unruh, MSW, LCSWA Intake Packet 1 Christina Unruh, MSW, LCSWA Initial Intake Packet Date CLIENT NAME: FIRST MIDDLE LAST Nickname: Date of Birth / / Age Address City Zip Code Phones: Mobile Home Work Preferred Phone: Mobile Home Work Is it okay to leave messages on your phone voic ? Yes No If yes, which contact number should I use to leave messages? PLEASE NOTE: By answering YES and indicating your choice of phone numbers, you are giving Christina Unruh, MSW, LCSWA permission to leave a voice message. Electronic communication is not secure and cannot be ensured under HIPAA or any other privacy laws. May I contact you by ? Yes No (PLEASE PRINT, MUST BE LEGIBLE FOR APPT REMINDERS) PLEASE NOTE: and all other electronic communication is not secure. All attempts are made to ensure privacy but privacy cannot be guaranteed under HIPAA or other privacy regulations. By completing this information you are accepting all risk pertaining to electronic communication. Date of Birth / / Gender: Male or Female Employer Occupation Are you a student? If so, where do you attend? Spouse/Partner's Name Children s Names and Ages Primary Care Physician: Address City/State/Zip

2 Christina Unruh, MSW, LCSWA Intake Packet 2 Physician Phone Fax Psychiatrist: (If applicable) Address City/State/Zip Phone Fax How did you learn about Christina Unruh, MSW, LCSWA? Name Phone Church Affiliation (if any) PERSON RESPONSIBLE FOR BILLING: Name: Relationship: Self Spouse Mother Father Step-Parent Guardian Other (Describe): Date of Birth: / / Address (if different) City Zip Code Phones: Mobile Home Work Use for appt. reminder also: Yes No IN CASE OF AN EMERGENCY CONTACT (required): Check if this contact is the same as Person Responsible for Billing, otherwise complete below. Name: Relationship to client: Phones: Mobile Home Work

3 Christina Unruh, MSW, LCSWA Intake Packet 3 Christina Unruh, MSW, LCSWA Client Concerns and Personal Information Please circle any area of concern: Please check all of the following problems/symptoms which apply to you. [ ] Panicky feelings [ ] No sense of purpose [ ] Nervousness [ ] Shyness [ ] Anxiety [ ] Loneliness [ ] Fears [ ] Relationship problems [ ] Phobic Avoidance [ ] Job problems [ ] Procrastination [ ] Educational problems [ ] Nervous tics [ ] Financial problems [ ] Driven to perform certain behaviors [ ] Career issues [ ] Headaches [ ] Boredom [ ] Chest pains [ ] Temper outbursts [ ] Rapid heartbeat [ ] Anger problems [ ] Dizziness [ ] Loss of control [ ] Excessive sweating [ ] Suspicious of others [ ] Appetite problem [ ] Hearing unidentified voices or sounds [ ] Weight loss/gain [ ] Guilt [ ] Bowel/stomach trouble [ ] Jealousy [ ] Bingeing [ ] Difficulty making decisions [ ] Vomiting [ ] Homicidal thoughts [ ] Purging [ ] Suicidal thoughts [ ] Muscle tension [ ] History of abuse [ ] Pain [ ] Flash backs [ ] Hearing problems [ ] Time loss [ ] Menstrual Problems [ ] Feeling out of body [ ] Sexual problems [ ] Feeling unreal [ ] Drug/alcohol abuse { ] Smelling unidentified odors [ ] Depression [ ] Sensitivity to noise or lights [ ] Unhappiness [ ] Racing thoughts [ ] Seasonal variations in mood [ ] Withdrawal [ ] Tearfulness [ ] Reduced Concentration [ ] Loss of interest [ ] Memory Problems [ ] Sleep Problems [ ] Low self-esteem [ ] Nightmares [ ] Fatigue Mental Health Is there a family history of (circle all that apply): Depression Anxiety Suicide Bipolar Disorder Psychosis substance abuse Have you attempted suicide? No Yes Do you currently have suicidal thoughts? No Yes

4 Christina Unruh, MSW, LCSWA Intake Packet 4 Do you occasionally think about what would happen if you were dead? Do you self-harm? Yes No Have you self-harmed in the past? Yes No Do you ever feel so angry you fear losing control? Yes No As a child did you have any problems with: Childhood History Learning disabilities Yes No Hyperactivity Yes No School fears Yes No Depression Yes No Sexual or physical abuse Yes No Did you have any other major childhood (0-17 years) school, learning, or emotional problems? No Yes If so, please describe: Family History Which of the following best describes the family in which you grew up? Warm and Accepting Distant, Hostile Typical Fighting Was the family/home disrupted by serious illness/accident/death/separation/divorce? No Yes If yes, please describe Previous Counseling or Chemical Dependency Services: Have you ever seen anyone or are you currently seeing anyone for: Individual Therapy No Yes Marital/Couples Therapy No Yes Group Psychotherapy No Yes Sex Therapy No Yes. Facility/Counselor Name Month/Year Seen

5 Christina Unruh, MSW, LCSWA Intake Packet 5 Reason Was treatment helpful? No Yes Have you experienced any unusually severe stresses during the past year? Yes No If yes, please describe: Job Satisfaction: Very Satisfied Fairly Satisfied Not At All Satisfied Have you ever taken work leave for mental health/chemical dependency problems? Yes No If Yes, How Long? Current health Poor Fair Good Excellent Medical/Lifestyle History Do you have any medical problems or diseases? Did you ever have a head injury? No Yes Did you ever have seizures? No Yes Medication(s) currently used: Medication/Dose/Date Prescribed/Reason/Prescriber: Do you take any herbal medications? No Yes, please name Past Hospitalizations (Psychiatric/Chemical Dependency) Date(s) Reasons Hospital Alcohol Use How often do you use alcohol? None Monthly Weekly Daily

6 Christina Unruh, MSW, LCSWA Intake Packet 6 On the days that you drink, how many drinks do you usually have? Less than or more Do you consider it a problem? No Yes; Do others consider it a problem? No Yes Do you have problems at work/school because of drinking or drug use? No Yes Have you had problems with alcohol in the past? No Yes Nicotine use Do you smoke or use tobacco now? No Yes, how much per day? Have you smoked or used tobacco in the past? No Yes Caffeine How many cups of caffeinated coffee/tea do you drink a day? How many caffeinated soft drinks? Marijuana Use: None Occasionally Daily Weekly Do you use other non-prescription substances? No Yes If yes, what substances? Do you take prescription substances more than prescribed? No Yes Legal History: None Litigation Arrest Victimization, specify Are you currently involved in a court case? No Yes If yes, which type? Have you/client ever experienced or witnessed a traumatic event? No Yes If yes, please explain:

7 Christina Unruh, MSW, LCSWA Intake Packet 7 Reason you/client is seeking counseling? How would you rate the seriousness of your problems? Not Very Slight Moderate Serious Extremely What specific behaviors, actions, feelings or habits would you or client (if minor) like to change? What are some of your special talents or skills? Please describe your social functioning/social life. Have you formulated goals for counseling at this point? Additional Notes: By signing, I agree the above information is true, to the best of my knowledge. *CLIENT/GUARDIAN S SIGNATURE DATE

8 Christina Unruh, MSW, LCSWA Intake Packet 8 Christina Unruh, MSW, LCSWA FINANCIAL SERVICES AGREEMENT I agree that I am responsible for the total balance due on my account for services rendered by Christina Unruh, MSW, LCSWA. I understand that Christina Unruh, MSW, LCSWA does not accept insurance of any kind and that if I desire to use my insurance, an appropriate referral will be provided to me. I understand that payments are due in full at the time service is rendered. Cash, Check, or Credit Card will be accepted. FEES: 53 Minute Therapy Session: Minute Clinical Assessment: $150 MISSED APPOINTMENTS/LATE CANCELLATIONS: Since I will be reserving appointment times in advance, I will bill your credit card for missed appointments or for appointments cancelled with less than 48 hours notice. COURT FEES: If my presence is required in court, a fee of $ per hour (with a 1-hour minimum charge) and an automatic 1-hour prep session fee is payable prior to the court date ($ retainer deposit). This includes my physical presence and standby phone testimony. OTHER PROFESSIONAL SERVICES: Payment schedules for other professional services (such as report writing, extended telephone conversations, consulting with other professionals with your permission, preparation of records or treatment summaries, or legal testimony) will be discussed and agreed to when they are requested. Christina Unruh, MSW, LCSWA reserves the right to decline to provide letters or reports as she deems appropriate. I accept credit cards and debit cards, personal checks, and FSA/HSA cards. There will be a $20 service charge for returned checks. If your account has not been paid for more than 60 days and you have not made arrangements for payment, I have the option of using legal means to secure the payment. This may include collection agency or small claims court which will require disclosing otherwise confidential information. I HAVE READ AND AGREE TO THE ABOVE FINANCIAL AGREEMENT POLICIES: CLIENT SIGNATURE DATE

9 Christina Unruh, MSW, LCSWA Intake Packet 9 Christina Unruh, MSW, LCSWA CLIENT S RIGHTS Christina Unruh, MSW, LCSWA provides services to clients on a nondiscriminatory basis without regard to gender, age, race, national origin, cultural background, religion, sexual orientation, disability, marital status or financial resources. I appreciate the opportunity to serve as your behavioral healthcare provider. As a client, you are entitled to certain rights to protect your dignity, privacy and individuality. They are summarized and guaranteed as follows: You have a right to access needed behavioral health services and a right to consent to or refuse treatment. You have a right to have the treatment of this group including access to medical care and habilitation without regard to age, race, color, creed, national origin, beliefs, values, mh/dd/sa disability, sex, sexual preference, handicap or source of payment. You have the right to expect humane and considerate treatment with respect for your personal dignity and privacy. You have the right to freedom from physical or mental abuse or harm. You are entitled to receive services in accordance with a specialized treatment plan designed to meet your needs. You can expect to participate in the planning of your treatment. You may obtain a copy of your treatment plan by verbally requesting it from your clinician. You are entitled to complete and current information concerning your diagnosis, treatment plan and progress in terms you can understand. You have a right to participate in decisions affecting your care. You have a right to authorize the release/disclosure of private information and know the release of this information may only occur with your written consent. You have the right to receive information about fees and payments for services as well as explanation of your bill regardless of how it is to be paid. You have the right to expect your personal privacy to be respected and all communications and records pertaining to your care to be kept confidential. Exceptions: 1) Privacy is waived by client or legal representative, 2) Disclosure is required to prevent imminent danger to yourself or others. You have the right to contact Disability Rights of NC (formerly Governor s Advocacy Council for Persons with Disabilities). CLIENT SIGNATURE DATE

10 Christina Unruh, MSW, LCSWA Intake Packet 10 CHRISTINA UNRUH, MSW, LCSWA MISSED APPOINTMENT POLICY The clinical relationship is best provided in a context of consistency and stability. The best care is provided and the best treatment plan progress is made when the clinician and client are dedicated to the process. A missed appointment fee will automatically be applied to your account whenever a client fails to be present at the scheduled appointment time, or when the scheduled appointment is cancelled (or rescheduled) with less than a full 48 hour notice of the booked appointment time. This fee is to be paid no later than the next scheduled appointment. If no further appointment is scheduled, the fee is due on the date of the missed appointment. The missed appointment and reason for the missed appointment will become part of the client s medical record. In order for appointments to be cancelled and/or rescheduled without incurring this fee, the client must contact their therapist 48 hours before the appt. You may always call, , or text to cancel your appointment. The payment software I use, Pocket Suite, has a feature that allows you to reschedule your appointment if you must cancel. Simply go to the text that was sent to you for confirming your appointment and press cancel. You can then follow the prompts. I understand emergencies and acute illnesses do sometimes occur and I will take this into consideration. Inclement weather may also be an issue. We will try to stay in communication with you via text about safety of travel. Chronic Missed Appointments: Christina Unruh, MSW, LCSWA may decide to terminate services for multiple missed appointments. At that time a referral to other providers will be made. Reminder: Christina Unruh, MSW, LCSWA provides an automated reminder 24 hours before the scheduled appointment time. If you would like us to remind you 48 hours or same day, please let us know and we can change that for you. CLIENT SIGNATURE DATE

11 Christina Unruh, MSW, LCSWA Intake Packet 11 Christina Unruh, MSW, LCSWA NOTICE OF HEALTH INFORMATION PRIVACY ACT THIS NOTICE DESCRIBES HOW MEDICAL AND PSYCHOLOGICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The law protects the privacy of all communications between a patient and a therapist. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by Health Insurance Portability and Accountability Act (HIPAA) and/or North Carolina Law. Uses and Disclosures for Treatment, Payment, and Health Care Operations Your protected health information (PHI) may be disclosed for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: "PHI" refers to information in your health record that could identify you. "Treatment, Payment and Health Care Operations" - Treatment is the provision, coordination or management your health care and other services related to your health care. An example of treatment would be consultation with another health care provider, such as your family physician or another therapist. - Payment is obtaining reimbursement for your healthcare. Examples of payment are when your health information is disclosed to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. - Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management and care coordination. "Use" applies only to activities within this practice such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. "Disclosure" applies to activities outside of this practice group, such as releasing, transferring, or providing access to information about you to other parties. Uses and Disclosures Requiring Authorization Your health information may be used or disclosed for purposes outside of treatment, payment, and health care operations only when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only

12 Christina Unruh, MSW, LCSWA Intake Packet 12 specific disclosures. In those instances when information for purposes outside of treatment, payment and health care operations is requested, your authorization will be obtained before releasing this information."psychotherapy notes" are kept separate from the rest of a medical record. These are notes made by a therapist about your conversation during a private, group, joint, or family counseling session, and are given a greater degree of protection than your general record. They cannot be released on a general Authorization Request for your medical record. Uses and Disclosures with Neither Consent nor Authorization Your health information may be used or disclosed without your consent or authorization in the following circumstances: Child Abuse: If you give information which leads your therapist to suspect child abuse, neglect, or death due to maltreatment, that information must be reported to the county Department of Social Services. If asked by the Director of Social Services to turn over information from your records relevant to a child protective services investigation, your therapist must do this. Adult and Domestic Abuse: If you provide information that gives your therapist reasonable cause to believe that a disabled adult is in need of protective services, this must be reported to the Director of Social Services. Health Oversight: The North Carolina Psychology Board, NC Board of Licensed Counselors, and NC Marriage and Family Therapy Board have the power, when necessary, to subpoena relevant records should your therapist be the focus of an inquiry. Judicial or Administrative Proceedings: If you are involved in a court proceeding, and a request is made for information about the professional services provided to you and/or the records thereof, such information is privileged under state law, and must not be released without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety: Your confidential information may be disclosed to protect you or others from a serious threat of harm by you. Worker's Compensation: If you file a workers' compensation claim, we are required by law to provide your mental health information relevant to the claim to both your employer and the North Carolina Industrial Commission. IV. Patient's Rights and Psychologist's Duties Patient's Rights: Right to Request Restrictions -You have the right to request restrictions on certain uses and disclosures of Protected Health Information about you. Your request must describe

13 Christina Unruh, MSW, LCSWA Intake Packet 13 in detail the restriction you are requesting. While we make every effort to honor your request, it may not be possible. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of Protected Health Information by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing someone. If you request it, your bills may be sent to another address.) Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of health information in the mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your therapist may deny your access under certain circumstances, but in some cases, you may have this decision reviewed. On your request, your therapist will discuss with you the details of the request and denial process. Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your therapist may deny your request. If you wish, your therapist will discuss with you the details of the amendment process. Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). If you wish, your therapist will discuss with you the details of the accounting process. Right to a Paper Copy - You have the right to obtain a paper copy of this notice upon request, even if you have agreed to receive the notice electronically. Each of the above rights may be exercised through a written request signed by you or your representative. Provider's Duties: Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI. Your provider reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, the current terms will apply. If policies and procedures are revised, you will be informed by mail of these revisions prior to any release of PHI. V. Complaints If you are concerned that your privacy rights have been violated, or you disagree with a decision about access to your records, you may file a written complaint with Christina Unruh, MSW, LCSWA of Cary Christian Counselor 1200 SE Maynard Rd. Ste. 104 Cary, NC You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, DC within 180 days of an alleged violation of your rights. VI. Effective Date, This notice will go into effect on November 1, If we make material changes to our privacy, practices, we will be provided copies of revised notices to all active clients.

14 Christina Unruh, MSW, LCSWA Intake Packet 14 CONFIDENTIALITY AND YOUR TREATMENT I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of our patient. These other professionals are also legally bound to keep the information confidential. Unless you object, I will only tell you about these consultations if we feel that it is important to our work together. All consultations will be noted in your Clinical Record. I practice with other mental health professionals, and I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All administrative staff have been given training regarding protecting your privacy and have agreed to not release any information outside of the practice without the permission of a professional staff member. I may use or disclose your health information for our normal health care operations. For example, credit card information is entered into my electronic device and that will include your name. Use and disclosure of your PHI for marketing purposes and the sale of PHI is not allowed without your written authorization. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. I cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, consult with your attorney to determine whether a court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. If a patient files a complaint or lawsuit against me, state law permits me to disclose relevant information regarding that patient in order to defend myself. LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a client and a therapist. As a licensed professional and a mandatory reporter in the State of North Carolina, there are some situations in which we are legally obligated to take actions that we believe are necessary to protect others from harm and in which we may have to reveal some information about a patient s treatment. These situations are unusual in my practice, but they include: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing your identity. The other professionals are also legally bound to keep the information confidential. You will not be told about these consultations unless your therapist feels that it is important to your work together.

15 Christina Unruh, MSW, LCSWA Intake Packet 15 I work administrative staff to ensure a safe and smooth therapy experience. In many cases, some protected information may be shared with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. I also have contracts with other vendors such as software providers and an accountant. As required by HIPAA, we have a formal business associate contract with any of these other businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. If I believe that a client presents an imminent danger to his/her health or safety, they may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. 3) There also are some situations where therapists are permitted or required to disclose information without either your consent or Authorization: If you are involved in a court proceeding and a request is made for information concerning the professional services that are provided to you, such information is protected by the therapist/client privilege law. Information cannot be provided without your written authorization, or a court order. 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 government agency is requesting the information for health oversight activities, we may be required to provide it for them. If a client files a complaint or lawsuit against a therapist, that therapist may disclose relevant information regarding that client in order to defend him/herself. If a client files a worker's compensation claim, and services are being compensated through workers compensation benefits, a therapist must, upon appropriate request, provide a copy of the client's clinical record to the client's employer or the North Carolina Industrial Commission. Professional records: The laws and standards of our profession require that we keep protected health information about you in your clinical record. You may examine and/or receive a copy of your clinical record if you request it in writing. In unusual circumstances in which disclosure is reasonably likely to endanger the life or physical safety of you or another person, we may refuse your request. In those situations, you have a right to a summary and to have your record sent to another mental health provider. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you

16 Christina Unruh, MSW, LCSWA Intake Packet 16 initially review them in our presence or have them forwarded to another mental health professional in order for you to discuss the contents. In most circumstances, the State of North Carolina permits a copying fee While this written summary of Confidentiality aims to be complete and exhaustive, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we, in situations where specific guidance is required, may need to seek formal legal advice. Expanded HIPAA Rights: HIPAA provides you with several new or expanded rights with regards to your clinical records and disclosures of protected health information. These rights include: requesting that we amend your record; requesting restrictions on what information from your clinical records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this agreement, the attached notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. For more information, you can also visit CLIENT SIGNATURE DATE

17 Christina Unruh, MSW, LCSWA Intake Packet 17 Christina Unruh, MSW, LCSWA THERAPIST-CLIENT SERVICES AGREEMENT This document contains important information about our practice and its business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect your privacy and your rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with the attached Notice of Privacy Practices that explains HIPAA and how it affects you. The law also requires that we obtain your signature acknowledging that you have received this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can address any questions you have about the procedures before your next session. When you sign this document, it will also represent an agreement between you, your therapist, and Christina Unruh, MSW, LCSWA. You may revoke this Agreement in writing at any time. That revocation will be binding except for information already disclosed or if you have not satisfied any financial obligations you have incurred. MENTAL HEALTH AND CONSULTATION SERVICES Services vary depending on your needs, and your therapist's approaches. There are many different methods used to deal with the issues that you hope to address. Your initial session(s) will involve an evaluation of your needs. By the end of the evaluation, your therapist will be able to offer you some first impressions of what your work will include and a plan to follow, if you decide to continue with our services. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist. Treatment/consultation involves a commitment of time, money, and energy, so you should be careful about the therapist you select. If you have questions about procedures, they should be discussed with your therapist whenever they arise. If your doubts persist, your therapist will be happy to help you set up a meeting with another professional for a second opinion. CONTACTING YOUR THERAPIST Therapists are normally not available by telephone because of client appointments. Your call will be received by your therapist s voice mail. Therapists do check their voice mail and make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please leave information about times when you will

18 Christina Unruh, MSW, LCSWA Intake Packet 18 be available. In emergencies, if the therapist has not responded to your call in the time you need, please call 911. YOUR DIAGNOSIS/CLINICAL RECORD To protect your privacy, your clinical record consists of your intake packet and general notes about the strategies I utilize in session. I do not keep a record of my impressions unless you report any information that would require me to break confidentiality (reporting self-harm or plans for suicide, etc..). I also will not include subjective opinion in your record that may be used against you if your record is ever subpoenaed. This includes diagnoses, which are not on file with me due to the fact that such information is required only by insurance companies. If you are going to file out of network benefits with your insurance, please be advised that I will assign a diagnosis to you per the insurance company s requirement, and this will become part of your clinical record. By submitting your invoices to your insurance company for out of network benefits you are giving your consent for a diagnosis to be in your clinical record. THERAPIST PSYCHOTHERAPY NOTES Christina Unruh, MSW maintains substantially limited psychotherapy notes to ensure privacy and maximize protection of clients in the event of litigation or other invasive requests for information. LITIGATION LIMITATION Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on your therapist, Christina Unruh, MSW, LCSWA, to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. I have carefully read the contents entire intake packet and understand and have asked questions to resolve any confusion. I understand my rights and these agreements regarding the aforementioned information. T Client Signature Date Therapist Signature Date

19 Christina Unruh, MSW, LCSWA Intake Packet 19 HIPAA Authorization Form For Release of Information PLEASE COMPLETE THIS FORM ONLY IF YOU WISH TO SHARE ANY CLIENT INFORMATION. OTHERWISE, YOU MAY DECLINE AT BOTTOM OF PAGE I AUTHORIZE Christina Unruh, MSW, LCSWA to share information with the parties indicated below. I acknowledge that Christina Unruh, MSW, LCSWA has taken measures to protect clients private health information. I understand that Christina Unruh, MSW, LCSWA will not release any information to anyone unless I have provided the requested information below. I acknowledge these would be people/agencies other than what is covered in the Notice of Privacy Practices provided to me. HIPAA (Health Insurance Privacy & Accountability Act) does not allow providers to release any information to outside entities on your behalf without your written consent. I am authorizing the person(s) listed below to obtain HIPAA information about myself. I understand that Christina Unruh, MSW, LCSWA is not responsible for the information provided as long as it is given to the person/people that I have listed below. I understand that I may revoke this authorization in writing at any time. Date of Birth must be provided so that our office can verify that we are speaking to the correct person.* 1. Name: Date of Birth: Relationship: 2. Name: Date of Birth: Relationship: 3. Name: Date of Birth: Relationship: 4. Name: Date of Birth: Relationship: OR DECLINE: I do not authorize Christina Unruh, MSW, LCSWA to release any of my protected health information to anyone other than the entities that are discussed in the Notice of Privacy Practices. *CLIENT/GUARDIAN S SIGNATURE DATE