LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292

Cancellation and No Show Policy Acknowledgement & Preferred Means of Contact

I have reviewed the Professional Disclosure Form and understand that if I do not provide 48-hour (2-day) notice prior to canceling an appointment or do not show for an appointment, my credit card on file will be charged a $35 missed appointment fee. I understand that the missed appointment fee will be due at the next session. Additionally, if I miss 3 appointments my case may be terminated at the discretion of this therapist.

Please check below at least two preferred means of communication for receiving information (i.e., appointment confirmation, emergency cancellation, etc.). Information sent by email is not secured and confidentiality cannot be guaranteed.

______Telephone – include number: ______

Is it okay to leave a voicemail: Yes No

______Email – list email address: ______

______

______US Mail – list address: ______

______

______Other (including fax): ______

______Signature of client or legal guardian

______Date

Revised 05/10/15 1 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292

Client Information Sheet

Date: ______

Name: ______First Middle Last

Date of Birth: ______SS#: ______

Home Address: ______Street PO Box ______City State Zip Code

Home Telephone: ( ) ______Work: ( ) ______

Cell Phone: ( ) ______Email: ______

Sex: Male Female Transgender

Race: White Black Indian Asian Hispanic Other

Marital Status: Single Married Separated Divorced Widowed Domestic Partners

Employment Status: Unemployed Employed Student Retired Homemaker

Military Status: Yes No Highest Grade Completed: ______

Primary Language: English Sign Language French Spanish Other

Living Arrangement: Private Residence Other ______

Emergency Contact Name: ______Relationship______

Home Telephone: ( ) ______Work ( ) ______

Legally Responsible Person (if client is child) ______Name Relationship Home Telephone: ( ) ______Work ( ) ______

Counseling Issues: (place a check next to the areas you wish to discuss)

__Relationship issues __health concerns __death/loss of sign. Other __Racial issues __suicidal thoughts __family problems __Cultural adjustment issues __career concerns __divorce/separation __Stress __anxiety __domestic violence __Depression __loss of employment __trauma __Lack of assertiveness __low energy __sexual/physical abuse __Alcohol/drug abuse __sleeping problems __legal issues __Development/self-esteem __religious/spirituality __parenting issues __Sexuality __marriage concerns __eating concerns REFERRED BY: ______

Revised 05/10/15 2 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292

How much are the issues checked above disrupting your life? □A minor disruption □somewhat of a disruption □an overwhelming disruption

Have you ever participated in counseling of any type? □Yes □No

Have you ever been hospitalized for a psychiatric problem? □Yes □No

Have you experienced any type of health problems over the last 2 years? □No □Yes—please explain: ______

Are you currently in the middle of a crisis? □No □Yes—please explain: ______

Are you feeling suicidal? □No □Yes, with thoughts only □Yes, with a plan Do you want to hurt someone? □No □Yes, with thoughts only □Yes, with a plan Do you have friends? □None □few □many Do you have someone you can talk to about personal problems? □Yes □No

Are you on any medications? □No □Yes, please list name, dosage, and prescribing physician:

MEDICATION DOSAGE PHYSICIAN

INSURANCE, PRIMARY CARE PHYSICIAN, AND REFERRING PSYCHIATRIST AUTHORIZATION I understand that if therapy is being paid for using insurance, LifeSkills will release any and all records pertaining to treatment to the insurance company, the primary care physician, or to your referring psychiatrist electronically, or by mail if such disclosure is necessary for claims processing, case management, coordination of treatment, or utilization review purposes. I hereby authorize payments for medical services rendered to myself to be made wither to me or on my behalf to LifeSkills. I understand that I am responsible for any amount not covered by my insurance.

Client’s Signature: ______Date: ______

Insured’s Signature: ______Date: ______

Revised 05/10/15 3 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 OFFICE POLICIES, GENERAL INFORMATION & CONSENT FOR TREATMENT FOR PSYCHOTHERAPY SERVICES

Welcome to the LifeSkills Counseling & Consulting Group, PLLC and thank you for choosing us. Please carefully read the following information because it will help you utilize our services most effectively. Feel free to ask any questions. This document contains important information about our professional services, business policies, and the current legal and ethical requirements for Licensed Professional Counselors and associates (including Interns and Supervisors of either license).

Please initial next to each paragraph:

_____ HIPPA CONSENT FORM: I have read and received the LifeSkills "Notice of Policies & Practices to Protect the Privacy of your Health Information" (also known as "HIPAA Consent") form. I understand that the document is also on LifeSkills’ website and is posted in the office. I understand that it describes how psychological and medical information about me may be used or disclosed and how I can gain access to this information. _____ NOTIFICATION OF CONSUMER RIGHTS: I have read and received the Notification of Consumer Rights. I understand that the document is also on LifeSkills’ website and is posted in the office. I understand that it explains that I have the right to dignity, to quality service, to refuse service, to least restrictive alternatives, to hearing and appeals, to support and advice, etc. _____ CONFIDENTIALITY: The information you share with us is confidential; that means that information about you does not leave our office without our consent or authorization. Exceptions to this policy are outlined more fully in the HIPAA Consent Form. Briefly, information may be disclosed only by if the following criteria are met or are necessary:  Diagnosis and date of service shared with your insurance company (if insurance is billed for treatment purposes)  Mandated reporting of physical or sexual abuse of children  Threats of suicide or homicide  Cases where you have signed a release of information for information to be disclosed  Information released as outlined in the HIPPA Consent Form In addition to the above, we sometimes consult with professional colleagues to improve the quality of care we provide. Your signature on this form constitutes advance consent for this practice. We do not use names or other identifying information when discussing “cases” with other professionals. They are also bound to keep this information confidential. We have an office assistant who has access to files, and she has signed a confidentiality agreement. We follow HIPPA procedures re: transportation of files. Records containing information about your visits are stored in a locked file cabinet.

______CULTURAL COMPETENCE: LifeSkills prohibits discrimination on the basis of race, color, national origin, age, disability, sex, marital status, familial status, parental status, religion, sexual orientation, political beliefs, or because all or part of an individual’s income is derived from any public assistance program.

______EMERGENCIES: * Outside of session: If there is an emergency while you’re a LifeSkills client where your therapist becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he/she will do whatever he/she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. He/she may also contact the person whose name you have provided as your emergency Revised 05/10/15 4 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 contact on the Personal Data sheet. For after-hours emergencies, call our crisis phone line at (704) 769-0217. For an emergent situations, please go to the local emergency room, or call 911. You can reach Presbyterian Behavioral Health Access at (704) 384-4255 or Carolinas Medical Center—Behavioral Health Center Emergency Room at (704) 358-2800 * Inside of session: Your therapist may also disclose your PHI (Protected Health Information) to others without your consent if you are incapacitated or in an emergency. For example, if you are in session with your LifeSkills therapist and begin to experience an anxiety attack, your therapist will not assume that it is anxiety-based, and may call for emergency medical treatment to insure that nothing more serious is happening for you medically.

______FINANCIAL ASPECTS OF CONTRACTING PSYCHOTHERAPY SERVICES: * Insurance Reimbursement: We will file insurance claims for you, and provide a receipt for payment for personal tax purposes. If your insurance plan has an unmet deductible or the claim is denied for service, you are responsible for payment. We encourage you to contact your insurance company to answer questions you may have about the extent to which our fees are reimbursable. We ask that you authorize payment of medical benefits directly to LifeSkills Counseling. We may use and disclose medical information about you so that the services received may be billed and payment may be collected. Please also understand that we may tell your health plan about the treatment you will receive in order to obtain prior approval and determine whether your plan will cover the proposed treatment. * Payment for Services (non-insurance): Fee for Service is determined by education level, licensure, and years of experience. The fee in working with a LifeSkills therapist is as follows: *$65--Individual Therapy and $80--Marital/Family Therapy with associates working toward licensure *$90—Individual Therapy and $115—Marital/Family Therapy with licensed therapists *there is a $15 administrative charge for all initial appointments. *Disability/Leave-from-work forms will be completed for $35.00 *Payments Due at Time of Service: Clients are expected to pay the standard fee per 45- minute session at check-in. Your appointment will be rescheduled if you do not have your copayment. You will not be able to schedule a subsequent appointment if you have an unpaid balance in our office.

______CANCELATION POLICY: *As a courtesy to you, we will confirm your appointment 1-2 days prior. Please do not rely on this as the only means of remembering your appointment as there could be technical circumstances that may prevent a call from going out. *Cancellation policy: If you give 48 hours’ notice to your therapist that you do not plan to attend your previously scheduled session, your therapist can take you off of his/her calendar without owing a session fee. However, without 48 hours’ notice, or “no-showing” for your appointment, you will be charged $35. This charge will incur on the credit card we have on file for you. You will be notified of the charge. *If you miss/cancel/no-show for 3 appointments, our office may terminate you as a client.

______SERVICES ASSOCIATED WITH LEGAL ISSUES AND/OR COURT PROCESS *Fees & Payment re: legal services: Requested documentation and court appearances including travel time, are $150.00 per hour. You should discuss with your therapist before sending a subpoena, because he/she will not often agree to appear in court and may be expected to refuse to give a professional opinion in court. The client or parent whose attorney issues the subpoena must pay $500 in advance of a court appearance, which will be refunded if she is notified in a timely manner that the appearance is not needed. Revised 05/10/15 5 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292

______THE PROCESS OF THERAPY/EVALUATION: * Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. Your LifeSkills therapist will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly to insure that your therapy is progressing toward your original goal(s). * Risks: During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Your therapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a positive decision for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift; but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. * Theoretical Orientation: During the course of therapy, your therapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, existential, family systems, developmental (adult, child, family), psychodynamic, or psycho-educational therapy.

______BOUNDARIES WITHIN THERAPY: * Phone Calls/Voice-mail & Emergencies: Given that we spend majority of our time in sessions, we are often not available by phone. When we are unavailable, the phone is answered by personal assistant or voicemail. We monitor our voicemail frequently. We will make every effort to return your call within 24 hours, with the exception of weekends and holidays. You may also contact us via email at [email protected] as we check email a few times a day. Emergency appointments can be made during regular business hours, and we will make every effort to accommodate this need. * Termination: Your LifeSkills therapist requests a two-week notice before therapy is terminated to process gains made during treatment, as well as issues to be addressed in the future either by him/her or another therapist. * Dual Relationships: The phrase “dual relationship” is used by the NC State Board of Examiners of Licensed Professional Counselors to describe when a therapist is not only serving a client in counseling, but also have a second point of contact, such as serving on a board together, or attending the same book study, etc. Not all dual relationships are unethical or avoidable. Some non-sexual dual relationships are unavoidable and rare examples can be clinically beneficial. Therapy never involves sexual or any other dual relationships that impair your therapist’s objectivity, clinical judgment and therapeutic effectiveness; this could be exploitative in nature. Your therapist will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients, discuss with each client the potential benefits and difficulties that may be involved in relationships and will discontinue the dual relationship if he/she finds it interfering with the effectiveness of the therapeutic process. In addition, if you encounter your therapist in any public setting, he/she will Revised 05/10/15 6 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 never approach you or even acknowledge you unless you first initiate contact so that he/she may protect your confidentiality and the nature of your professional relationship.

______GRIEVANCES: If you are dissatisfied with any aspect of our work, please talk with us about it. If you think you have been treated unfairly or unethically, and we cannot resolve the problem, you can contact the NC Board of Licensed Professional Counselors, PO Box 77819, Greensboro, NC 27417, for clarification of clients’ rights as I’ve explained them to you or to lodge a complaint. All grievances will be attended to within 5-10 business days.

I have carefully read, understand, and agree to comply with the above Office Policies, General Information, and Consent for Treatment for psychotherapy services with LifeSkills Counseling & Consulting Group, PLLC.

______Client Name (print) Signature Date

______Parent Name (Print) — (If client is a Signature Date

Minor, under 18) ______LifeSkills therapist Name (Print) Signature Date

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DATE: ______

Insurance Coverage Worksheet

Client Name: ______ID#: ______

Date of Birth: ______SSN: ______

Medicaid Y N If yes, ID#: ______

Medicare Y N If yes, ID#:______

Insurance Y N If yes, ID#:______

Name of Primary Insurance Company: ______

Policy ID#:______

Policy Group#:______

Employer Name: ______

Policy Holder Name: ______

Policy Holder SSN: ______

Relationship to Client: ______Sex: M F DOB: ______

Insurance Company Address: ______

Insurance Company Telephone: ______

Insurance Authorization Number: ______

If not on the insurance panel for this client’s carrier, are there out of network benefits: ______

Insurance Copay ______Insurance %: ______Client%: ______

Insurance Deductible: ______Deductible Met: ______

Insurance Reimbursement Rate: ______# of Approved Sessions: ______Revised 05/10/15 8 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 Client Rights  To be treated with respect and dignity

 To have your privacy protected

 To develop a plan of café with services to meet your needs

 To participate in decisions regarding care

 To request information about names, locations, phones, and language for local agencies

 To receive the amount and duration of services you need

 To be free from use of seclusion or restraints

 To receive age culturally appropriate services

 To understand available treatment options and alternatives

 To refuse any proposed treatment

 To receive care that does not discriminate against you (e.g. age, race, type of illness)

 To be free of any sexual exploitation or harassment

 To receive any explanation of all medications prescribed and possible side effects

 To receive treatment, including access to medical care and habilitation, regardless of age or degree of MH/DD/SA disability

 To file a request for an administrative (fair) hearing

 To request and receive a copy of your medical records and ask for changes. You will be told the cost for the copying

Revised 05/10/15 9 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 NOTICE OF POLICIES AND PRACTICES TO PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION

This notice describes how psychological & medical information about you may be used or disclosed and how you can get access to this information. Please review it carefully.

I. Disclosures for Treatment, Payment and Health Care Operations A LifeSkills therapist may use or disclose your protected health information (PHI), for certain treatment, payment, & health care operations purposes without your authorization. In certain circumstances, he/she can only do so when the person or business requesting your PHI provides a written request that includes certain promises regarding protecting the confidentiality of your PHI. To help clarify these terms, here are some definitions: • “PHI” refers to information in your health record that could identify you. • “Treatment” is when a therapist or another healthcare provider diagnoses or treats you. An example of treatment would be when a therapist consults with another health care provider, such as your family physician or another psychologist, regarding your treatment. • “Payment” is when a therapist obtains reimbursement for your healthcare. • “Use” applies only to activities within LifeSkills such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. • “Disclosure” applies to activities outside of LifeSkills such as releasing, transferring, or providing access to information about you to other parties. • “Authorization” means written permission for specific uses or disclosures.

II. Uses and Disclosures Requiring Authorization A therapist may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment and payment operations, your therapist will obtain an authorization from you before releasing this information. You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time; however, the revocation or modification is not effective until we receive it.

III. Uses and Disclosures with Neither Consent nor Authorization A therapist may use or disclose PHI without your consent or authorization in the following circumstances: • Child Abuse: Whenever a therapist, in his/her professional capacity, has knowledge of or observe a child he/she knows or reasonably suspects has been the victim of child abuse or neglect, he/she must immediately report such to a police department, sheriff’s department, county probation department, or county welfare department. Also, if a therapist has knowledge of or reasonably suspects that mental suffering has been inflicted upon a child or that his/her emotional well-being is endangered in any other way, the therapist may report such to the above agencies. • Adult and Domestic Abuse: If a therapist, in his/her professional capacity, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder or dependent adult; if a therapist is told by an elder or dependent adult that he/she has experienced these; or if a therapist reasonably suspects such, the therapist must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency. A therapist is not required to report such an incident if the therapist has been told by an elder or dependent adult that he/she has experienced behavior constituting physical abuse, abandonment, abduction, isolation, financial abuse or neglect and the therapist is not aware of any independent evidence that corroborates the statement that the abuse has Revised 05/10/15 10 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 occurred; (a) the elder or dependent adult has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservator ship because of a mental illness or dementia; and (b) in the exercise of clinical judgment, the therapist reasonably believes that the abuse did not occur. • Health Oversight: If a complaint is filed against a therapist with the Texas State Board of Examiners of Licensed Professional Counselors, the Board has the authority to subpoena confidential mental health information from the therapist relevant to that complaint. • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that I have provided you, I must not release your information without (a) your written authorization or the authorization of your attorney or personal representative; (b) a court order; or (c) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court- ordered. Your therapist will inform you in advance if this is the case. • Serious Threat to Health or Safety: If you communicate to your therapist a serious threat of physical violence against an identifiable victim, he/she must make reasonable efforts to communicate that information to the potential victim and the police. If he/she has reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, he/she may release relevant information as necessary to prevent the threatened danger.

IV. Patient's Rights and Therapist’s Duties Client’s Rights: • Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of your PHI. However, your therapist is not required to agree to a restriction you request. • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a therpaist. Upon your request, your therapist will send your bills to another address.) • Right to Inspect and Copy – You have the right to inspect or obtain a copy of PHI in your 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 to PHI 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/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, but I 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). On your request, 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 the notice from LifeSkills upon request, even if you have agreed to receive the notice electronically. Therapist’s Duties:

Revised 05/10/15 11 LifeSkills Counseling & Consulting Group Record # 8401 Medical Plaza Drive, Suite 355 Charlotte, NC 28262 Phone: (704) 548-5299, Fax (704) 548-5292 • Your therapist is required by law to maintain the privacy of PHI and to provide you with a notice of LifeSkills’ legal duties and privacy practices with respect to PHI. • Your therapist reserves the right to change the privacy policies and practices described in this notice. Unless he/she notifies you of such changes, however, he/she is required to abide by the terms currently in effect.

V. Complaints • If you are concerned that a therapist has violated your privacy rights, or you disagree with a decision he/she has made about access to your records, you may contact LifeSkills’ Clinical Director, LaTonya M. Summers, MA LPC, at 704-548-5299. • You may also send a written complaint to the Secretary of the U.S. Department of Health & Human Services. The person listed above can provide you with the appropriate address upon request.

VI. Effective Date, Restrictions and Changes to Privacy Policy This notice will go into effect on April 7, 2007. LifeSkills reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that Lifeskills’ therapists maintain. LifeSkills will provide you with a revised notice by U.S. Mail.

Revised 05/10/15 12