Intake Packet

Holston Center

for

Wellbeing

Kathy T. Heustess, MAR, MSW, LCSW Conference Pastoral Counselor

Client Confidential Intake Information Please carefully respond to questions

Name: ________________________________

Date: ______________________________

Home Address: _________________________

Date of Birth: _______________________

Email address: __________________________

Cell: ______________________________

Marital Status:

 Single

 Married

 Divorced

 Separated

 Widowed

Employment: __________________________________________________________________ Referred by: ___________________________________________________________________ Permission to contact referral source to acknowledge that you followed up on your appointment?  Yes

 No

________________________________ Signature please

Religious affiliation: _____________________________ Active?  Yes

Family – Please check those living in your home.

 No

Please mark X those who are deceased.

Current Spouse/partner _______________________

Age ____ Father _________________

Age ___

Date of Marriage ____________________________

Mother _________________

Age ___

Children ___________________________________

Age ____ Siblings ________________

Age ___

__________________________________________

Age ____

______________________

Age ___

__________________________________________

Age ____

______________________

Age ___

__________________________________________

Age ____

______________________

Age ___

Others ____________________________________

Age ____

______________________

Age ___

__________________________________________

Age ____

______________________

Age ___

Prior Marriage(s) If you have been previously married, please give the following dates and information: First marriage from ________ to _________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________ Second marriage from ________ to ________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________ Third marriage from ________ to ________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________

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Spouse Prior Marriage(s) If your present spouse has previous marriages, please list the dates and information: First marriage from ________ to _________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________ Second marriage from ________ to ________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________ Third marriage from ________ to ________ Reasons ended: ________________________________________________________________________ _____________________________________________________________________________________

Medical Physician routinely seen: ________________________________ Phone: __________________________ Specialty: _________________________________________

Address: __________________________

Current medications: ____________________________________________________________________ _____________________________________________________________________________________ Briefly describe any current medical problems: _______________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________  Check here if you would consent to consultation with primary care physician regarding your mental health.

Counseling or Therapy Please discuss any previous counseling or therapy _________________________ ______________________ _________________________ ______________________ _________________________ ______________________

____________________ ____________________ ____________________

For Clergy Only: Appointment history

Level of Education _______________________________

Charge 1 _______________________________

Years __________________________

Reason for appointment change ___________________________________________________

Charge 2 _______________________________

Years __________________________

Reason for appointment change ___________________________________________________ Charge 3 _______________________________

Years __________________________

Reason for appointment change ___________________________________________________ Charge 4 _______________________________

Years __________________________

Reason for appointment change ___________________________________________________ Charge 5 ______________________________

Years __________________________

Reason for appointment change ___________________________________________________ _____________________________________________________________________________

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Present Concerns Please identify any that are of CONCERN TO YOU. Check all that apply.  anger release/temper  family problems  marriage problems  child rearing problems  decision making  work/job  vocational discernment  decision making  eating/loss of appetite  suicidal thoughts

 feelings of hopelessness  feelings of helplessness  feelings of worthlessness  fear and anxiety  general unhappiness  religious/spiritual issues  hearing/seeing things  sleeplessness or too much sleep  alcohol/drugs/tobacco  finances

 friendships  sexual concerns  moving  others (please list) ______________________ ______________________ ______________________ ______________________ ______________________ ______________________

1. What is your MAIN reason for seeking counseling at this time?

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. List several goals you would like to achieve through counseling: A. B. C. D. 3. Please describe any significant problems or stressors you are experiencing and for how long: a. Mental or Emotional: ____________________________________________________ b. Family Relationships: ___________________________________________________ c. Work or School:________________________________________________________ d. Health: _______________________________________________________________ e. Legal Concerns: ________________________________________________________ f. Financial Pressures: _____________________________________________________ 4. How would you rate your use of alcohol, tobacco, or drugs? List substances and how often. _____________________________________________________________________________ 5. Do you suspect you misuse any prescription medications? _____________________________ 6. Are you concerned about your physical safety? Please explain: _________________________ _____________________________________________________________________________ 7. Please rate the following areas in your life: “S” for areas you are Satisfied or “D” for areas you are Dissatisfied with: _______Housing/Living Situation

______ Spouse/Partner Support

______ Education

_______Employment/Work Situation

______ Relationships with Friends

______ Financial Situation

_______Family Support

______ Ability to Care for Yourself

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8. Family History: Please check the following problems that have occurred and note if occurred in: a) your immediate family, b) the family you grew up in, c) other relatives, or d) yourself.  Substance abuse (alcoholism, drug abuse)

 Family “secrets”

 Other addictions

 Infidelity

 Sexual Abuse

 Chronic lying

 Physical Abuse

 Children out of wedlock

 Mental or emotional abuse

 Abortion

 Depression

 Divorce

 Suicide or attempted suicide

 Religious abuse

 Mental Illness

 Eating Disorders

9. What physical, mental or emotional SYMPTOMS have you experienced recently? Check all that apply.  Muscle twitches

 Wish you could go to sleep and never wakeup

 Decrease in energy or fatigue

 Impaired memory (forget things more than usual)

 Hyperactivity

 Racing thoughts or speech

 Impulsiveness

 Tendency to go off on tangents

 Sexual problems

 Difficulty speaking

 Restlessness

 Racing heart

 Problems at work, school or academics

 Anxiety

 Over-aggressiveness

 Fear of abandonment

 Withdrawn from family or friends

 Panic attacks

 Stealing or dishonesty

 Excessive worry

 Destructiveness

 Flashbacks of distressing events

 Disorganization

 Phobias or excessive fears

 Trouble with authority figures

 Afraid of open spaces

 Breaking rules, pushing limits

 Nervousness

 Injuring self (such as cutting, pulling hair, etc.)

 Unsure of what is real

 Trouble with sleep (too much, too little, insomnia, etc.)

 Feel like you are outside your body watching yourself

 Anger or hostility

 Sometimes think you are hallucinating

 Apathy

 Obsessions, trouble getting thoughts out of your mind

 Depressed mood or lingering sadness

 Excessive fears of:____________________

 Crying spells or tears come easily

 Concerns others are spying or trying to poison you

 Emotional highs

 Suicidal thoughts or wishes

 Feeling guilty

 Murderous thoughts or wishes

 Helplessness

 Eating disorder (starving, binging or purging)

 Hopelessness

 Emotional eating

 Irritability

 Unable to maintain normal weight

 Feelings of rejection

 Dissatisfied with body shape or weight

 Low self-esteem

 Concern over your use of alcohol or tobacco

 Reduced interest or enjoyment in life

 Concern over your use of drugs

 Noticeable mood swings

 Persistent desire for alcohol, tobacco or drugs

 Easily distracted

 Chronic Pain

 Difficulty making decisions

 Medical conditions:____________________

Please fax this information\to Holston Center for Wellbeing (865) 692-2393 or return to counselor by the second visit.

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Holston Center

for

Wellbeing

Kathy T. Heustess, MAR, MSW, LCSW Office: (865) 692-2390

Counseling Services Agreement

CLIENT RIGHTS 1.

2.

3.

4.

5.

6.

7.

8.

Credentials of the counselor: I have education and training in an accredited university program and hold a Masters degree in Social Work. (MSW). I am licensed by the State of Tennessee as a Licensed Clinical Social Worker (#6787). Also, I am an Ordained Deacon in the United Methodist Church with a Master of Arts in Religion.

The counseling process will be explained to you when you meet with the counselor. You have the right to ask questions and express any concerns you may have about the counseling process. If at any time you decide you wish to end the counseling relationship, I will provide you with a list of qualified professionals whose services you might prefer. You may decide to end counseling and you may do so without any obligations, either moral or legal or financial, to me. If you make this decision on your own without consulting me, I ask that you give me notice by telephone.

Counseling notes are available to you, if you wish to read them. If a client is a child or adolescent under 18 years of age referred by parents, custodial parents have a right to all information shared in the session.

If you request it, any part of your record in the files can be released to any person or agency you designate. I will advise you at the time about potential harm to you, if any, in releasing the information.

You have the right to confidentiality. Within limits of the law, information revealed by you during counseling will be kept strictly confidential and will not be revealed to any other person or agency without your written permission.

There are certain situations in which I am required by law to reveal information obtained during counseling to other persons or agencies without your permission. Also, I am not required to inform you of my actions in this regard.

These situations are: (a) If you threaten grave or bodily harm or death to yourself or another person, I am required by law to inform the intended victim and appropriate law enforcement agencies; (b) If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in that order; (c) If you reveal information relative to child abuse, child neglect, or elder abuse, I am required by law to report this to the appropriate authority; and (d) If you are in therapy by order of a court of law, the results of the treatment ordered must be revealed to the court.

Most clients are self-referred. If you are referred by a supervisor and desire that progress reports be written as to your progress in therapy, you will sign a written release to this effect.

You and counselor both agree to the counseling relationship. Goals for therapy are set collaboratively, with all persons involved, early in the process and relate to the specific presenting problem.

AGREEMENT ACKNOWLEDGEMENT 1.

2.

3.

I agree to enter into therapy with Kathy T. Heustess, MSW, LCSW and Licensed Clinical Social Worker.

I understand that I can leave therapy at any time and that I have no moral, legal, or financial obligation.

I will give a twenty-four hour notice by phone, if possible, for cancellation of a scheduled session.

Client(s): ________________________________________ ________________________________________ Therapist: ________________________________________

Date: _________________________________

Please fax this information\to Holston Center for Wellbeing (865) 692-2393 or return to counselor by the second visit.

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Holston Center for Wellbeing Kathy T. Heustess, MAR, MSW, LCSW Office: (865) 692-2390

Communication Authorization Form Completion of this document authorizes the office of Kathy T. Heustess to contact you to leave certain information on your phone messaging system, e-mail or text messaging. Although every precaution will be taken by the Holston Center for Wellbeing to ensure confidential communication with you, there are inherent risks involved with each of these methods, some of which are mentioned here. Please read and complete each section. This office will not communicate or respond to your requests (through e-mail or text messaging) until you have signed this authorization form permitting us to do so. You may revoke this authorization at any time and you have a right to a copy of this authorization. Please note that refusal will not affect your ability to obtain counseling.

Client Name: _______________________________

Date: ______________________

TELEPHONE (voicemail) for Face-to-Face Consultations only Please note that if you opt for online telemental health consultations you will need to choose either text or email contact for appointment reminders as they will contain the link to log into your session.

RISKS: Conversations on cellphones can be intercepted by third parties. Voice messages on phone systems can be accessed by other users (family, co-workers, etc.) Provide only those numbers where contact is permitted or preferred. Please note that all urgent communication will be conducted by telephone and if you opt to decline permission to leave messages, we will make reasonable attempts (within normal business hours) to reach you prior to your next appointment.

I hereby authorize the office of Kathy T. Heustess to call the following telephone/cell numbers:

Cell: _____________________________________ Home: ____________________________________ Other: ____________________________________ (please specify) and leave a detailed message/voicemail with the following information:  Appointment time (schedule, change or cancel)  I further authorize the office of Kathy T. Heustess to leave messages about appointment times (confirmation, changes or cancellations) with the following person(s) _____________________________

________________________________

name

relationship

_____________________________

________________________________

name

relationship

 I DECLINE. Please do not leave any messages.

Please fax this information\to Holston Center for Wellbeing (865) 692-2393 or return to counselor by the second visit.

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ONLINE COMMUNICATION (e-mail) RISKS: It is possible that e-mail messages may not be sent or received through a “secure” or encrypted service. I understand that it is easier for online communication to be forwarded, intercepted, or even changed without my knowledge. By using a standard e-mail or e-mail system provided by an employer, I understand that employers have a right to inspect and keep online communication transmitted through their system. I know that messages left on my screen may be viewed by others. I understand that online communication should not be used to communicate highly sensitive and very confidential messages. Urgent messages should not be communicated through email.

I hereby authorize the office of Kathy T. Heustess to use the following email address __________________________________ and send or respond to detailed messages with the following information:  Appointment time (schedule, change or cancel)  I DECLINE. Please do not send any e-mail messages.

TEXT MESSAGING (texting) RISKS: Text messages can be circulated, forwarded or stored in electronic files. Senders can easily misaddress a text message and therefore be immediately broadcast and received by unintended recipients. Text messages can be intercepted, altered, forwarded without detection or authorization. Text messages can also be lost in transmission.

I hereby authorize the office of Kathy T. Heustess to use the following address(es)

Cell: _______________________________

Email: ___________________________

and leave a detailed message with the following information:  Appointment time (schedule, change or cancel)  I DECLINE. Please do not send any text messages.

APPOINTMENT REMINDER NOTIFICATION Please indicate your preference for appointment reminders ranked 1 - 3 (1 being preferred, 3 being least preferred).

We will contact you using your preferred method, however should that fail we will use the next method you’ve chosen.

______ Cell/Home*

_______ Email

_______ Text

* cannot be used for online telemental health consultations

ACKNOWLEDGEMENT I have read and fully understand this consent form. I understand the risks as outlined above. I understand that it is my responsibility to provide updated contact information (telephone numbers, e-mail and text messaging addresses) if I choose to be contacted.

Client signature: ____________________________

Date: _______________________

Counselor signature: _________________________ Please fax this information\to Holston Center for Wellbeing (865) 692-2393 or return to counselor by the second visit.

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Kathy T. Heustess, MAR, MSW, LCSW

Online Counseling Consent Form Terms & Conditions for Online Counseling Services: Clients interested in receiving online counseling services must be at least 18 years-old.

If it is determined that online counseling is appropriate, clients must submit written verification to the terms and conditions (see below) before services are rendered.

Eligibility for Online Counseling Services: Online counseling services are not meant to take the place of direct, face-to-face psychotherapy services.

Online counseling services are most suitable for clients over the age of 18 years-old who have either previously engaged in formal counseling services and/or are seeking short-term support for issues that are unrelated to a major crisis, severe mental health issues, suicidal, homicidal or violent behavior (past and present).

Although online counseling services may be helpful, direct, face-to-face services are highly recommended and encouraged, especially for clients either looking for long-term treatment, clients in crisis or diagnosed with major mental health issues.

Online counselin does not provide crisis counseling and is not intended for clients who: 1) 2) 3)

Have a history of major psychiatric episodes, hospitalizations or drug/alcohol dependence.

Have been diagnosed as any of the following - Borderline Personality Disorder, Major Depressive Disorder, Bipolar Disorder Type 1, Mentally Ill/Chemically Addicted (MICA), and/or Schizophrenia.

Have a history of suicidal, homicidal or violent behavior or present as suicidal, homicidal or violent.

If you are considering suicide, or believe yourself to be a potential safety threat to others, you must immediately call 911, or seek emergency care at your local hospital.

Full Client Mental Health Disclosure & Right To Refuse Online Counseling Services: If you have any history of major psychiatric episodes, hospitalizations or drug/alcohol dependence or have been diagnosed as any of the following - Borderline Personality Disorder, Major Depressive Disorder, Bipolar Disorder Type 1, Mentally Ill/Chemically Addicted (MICA), and/or Schizophrenia -YOU MUST disclose this information to Kathy Heustess prior to being considered for online counseling services.

Failure to do so or knowingly misleading or withholding the above said information excludes Kathy Heustess from any legal obligation or liability related to said client’s diagnosis, prognosis, outcome and actions.

Online counseling is meant for clients who are not in major crisis nor been diagnosed with major mental health issues.

Privacy Policy: According to mental health licensing statutes, the law protects the privacy of all communications between a client and practitioner. Kathy Heustess’s practice is in compliance with the requirements of HIPAA. Confidentiality is taken seriously and discussing or releasing your information to any individual, agency, or corporation except if such release is requested by a signed authorization form; or if a client indicates intent to do harm to her/himself or others.

Please indicate that you have read and understand the terms and conditions of online counseling by providing your signature below.

____________________________________________________ Signature

_____________________________ Date

Please fax this information\to Holston Center for Wellbeing (865) 692-2393 or return to counselor by the second visit.

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