Pathways Counseling & Wellness Consumer Information Sheet

I. General Information Name: ______Date: ______Date of Birth: ______Social Security:______Address: ______May we send mail to your home address? [ ]yes [ ]no May we contact you via email? [ ]yes [ ]no If yes, please provide email address: ______Gender: [ ]male [ ]female Marital Status: [ ]single [ ]married [ ]separated [ ]divorced Religion: ______Primary language: ______Employer: ______Job Title: ______Phone Daytime: ______Evening: ______May we leave messages for you? [ ]yes [ ]no Who may we contact in case of emergency? Name: ______Phone: ______Relationship: [ ]spouse [ ]parent [ ]relative [ ]other:______

II Insurance Insurance provider: ______Policy or ID Number: ______Deductible:______Co-pay: ______Has deductible been met? [ ]yes [ ]no If no, remaining amount ______Co-insurance? [ ]yes [ ]no Provider and ID number:______

III. Medical Primary Care Physician: ______Please list any current or past medical conditions: ______Current Medications (name, dosage): ______Past Hospitalizations (when, where, reason): ______

IV. Treatment Presenting Issue: ______Have you ever attended therapy before: [ ]yes [ ]no If yes, please list therapist and dates: ______Please list any other services you receive (i.e., psychiatric care, mental health services, case management, etc.): ______

V. Client History Please check any events or issues that you have experienced: [ ] physical abuse [ ] cutting [ ] sexual abuse [ ] running away [ ] domestic violence [ ] fire setting [ ] anxiety [ ] destruction of property [] panic attacks [ ] insomnia [ ] depression [ ] change in appetite [ ] rape [ ] head injury [ ] alcohol abuse/dependency [ ] bed wetting [ ] drug abuse/dependency [ ] memory problems [ ] suicidal thoughts [ ] nightmares [ ] suicide attempts [ ] incarceration [ ] homicidal thoughts [ ] seizures [ ] homicidal attempts [ ] sexual behaviors [ ] psychiatric hospitalizations [ ] victim/witness violent crime [ ] grief/loss [ ]serious accident/injury [ ] anger outbursts Pathways Counseling & Wellness Consumer Acknowledgement of Services

I. RIGHTS AND RESPONSIBILITIES As a consumer of service, whether a youth/adult/parent/legal guardian I am aware that I have certain rights and responsibilities as a participant in the service. I have the right to be treated with respect and dignity and to be free of abuse, neglect, exploitation and physical punishment. I have the right to treatment, including access to medical care and habilitation, regardless of age or degree of MH/IDD/SA disability. I have the right of informed consent – to have services explained in a manner I can understand. To be informed what is to happen, expectations, benefits, hazards, and alternatives to the service. Informed consent offers me a way to participate in service planning and provision. I have the right to have all information about myself and/or my family to be kept in confidence. Confidential information includes all forms, written, verbal, audio or videotapes, and electronic. Under law there are times when the right to confidentiality is no longer valid. These such times can be found in the General Statutes or in 45 CFR 164.512 of HIPPA and include: a. Upon receipt of a court order to release information b. In the event of a medical emergency c. When there is suspicion of abuse and/or neglect d. When there is a danger to self or others and/or threats of harm to self or others Certain information about services may also be provided to an insurance or billing entity. I have the right to choose a service provider agency or organization and to refuse service altogether. In the refusal of service, I take upon myself the consequences of such actions. I am aware that program or service design may require restriction of basic consumer rights to maintain the consumer in a safe, healthy and nurturing environment. I have the right to make complaints about the service of Pathways Counseling & Wellness. I am responsible to communicate my complaint in writing to my counselor and her licensing board. I am responsible to be an active participant in the plan of care/service.

X______I am aware and understand my rights and responsibilities as provided to me. X______I am aware that I can refuse treatment.

II. INFORMED CONSENT X______I am aware of the counseling services planned for myself/my child. I will participate in the development of a service plan and agree to its content. I am aware of the benefits and potential risks of the program/service. I have been provided the opportunity to discuss the plan of service and possible alternatives. I agree to participate in the program and understand my participation is voluntary. I agree to participate in outpatient counseling services offered by Pathways Counseling & Wellness.

 AUTHORIZATION TO PROVIDE SERVICE X______I authorize Pathways Counseling & Wellness to provide service to my child/myself/my family. I understand that participation is voluntary and I may discontinue service at any time. I understand that my insurance provider may be billed for the services received and the primary care physician may be contacted for authorization of these services. I understand that Pathways Counseling & Wellness is required to notify the referring agency of my participation, withdrawal, or dismissal from services, when applicable. I have full understanding of the items initialed above and have been provided with a copy of this form. A copy will be retained in my child’s/my case record. I have been given the opportunity to ask questions and seek explanation for any items that I do not fully understand. I voluntarily agree to participate in the program/service as documented in my service plan.

Client Signature:______Date: ______Parent/Legal Guardian Signature: ______Date: ______

Clinician: ______Date: ______

Pathways Counseling & Wellness Service Agreement

The following services are currently offered by Miki Gordon of Pathways Counseling & Wellness: individual and family therapy, development of an appropriate service plan, and referral to other community resources. Services NOT offered by Miki Gordon include, but are not limited to: custody evaluations, court ordered evaluations, court testimony, psychiatric assessments or evaluations, medication management, inpatient treatment, substance abuse treatment, and case management. If Miki Gordon is subpoenaed to court, I agree to a fee of $200 per hour that will be billed to the client or guardian.

I am aware of the types of services offered by Miki Gordon of Pathways Counseling & Wellness. I agree that if I require services other than those currently offered by Miki Gordon, I am responsible for securing those services elsewhere. I will have Pathways Counseling and Wellness phone number and the cell phone number for Miki Gordon or a designated alternative counselor in case of an emerging crisis to use after hours. In case of a life threatening emergency, consumers should call 911 or go immediately to the emergency room.

Pathways Counseling & Wellness (the “Group”) is an affiliation of individual therapists and counselors who share office space, and operate, not as partners, but instead as independent contractors who share no clinical responsibilities unless otherwise specified in the client’s agreement for service. Neither the Group, nor any other therapist or counselor, has any professional responsibility for any acts or omissions of any other counselor or therapist affiliated with the Group.

______Signature of Consumer Date

______Witness Date NOTICE OF PRIVACY PRACTICES OF Pathways Counseling & Wellness

Pathways Counseling & Wellness must collect timely and accurate health information about you and make that information available to members of your health care team in this agency, so that they can accurately diagnose your condition and provide the care you need. There may also be times when your health information will be sent to service providers outside this agency for services that this agency cannot provide. It is the legal duty of Pathways Counseling & Wellness to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care.

The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used within Pathways Counseling & Wellness, as well as reasons why your health information could be sent to other service providers outside of this agency.

This Notice describes your rights in regards to the protection of your health information and how you may exercise those rights. This Notice also gives you the names of contacts should you have questions or comments about the policies and procedures Pathways Counseling & Wellness uses to protect the privacy of your health information.

Please review this document carefully and ask for clarification if you do not understand any portion of it.

Client Acknowledgement

I have received Pathways Counseling & Wellness’s Notice of Privacy Practices, which describes their methods for protecting the privacy of my health information that is used in providing health care services to me.

______/______Client (or Personal Representative) Date

Note: Agency retains this signed page. Client retains the Notice of Privacy Practices document. Professional Disclosure Statement Consent for Treatment Pathways Counseling & Wellness Miki Gordon, MA, NCC, LPC 5170 Hwy 105 S, #1 Banner Elk, NC 28604 Phone: 828-260-2031 [email protected]

Qualifications:

Miki Gordon holds a Bachelor Degree in psychology (1998) and a Masters Degree in School Counseling from Appalachian State University (2002). She has been involved in providing clinical services since 2001, and has worked with children, adults and families in a variety of settings.

Consent to treat:

I freely give my consent to be treated by Miki Gordon. I understand that these services may include but are not limited to:

1. Assessment, evaluation, and diagnosis 2. Developing a treatment plan 3. Psychotherapy 4. Additional referrals as needed 5. Release of information as designated by written permission 6. Follow up treatment as needed.

I understand that I may deal with difficult emotional issues, which may, at times, lead to unanticipated emotional stress, as well as emotional improvement. I understand that there are no warrantees or guarantees of a particular outcome given or implied.

Miki Gordon treats families, couples, and individuals from a systemic perspective. Theoretically she applies a variety of treatment strategies that will best fit the client’s needs. These theoretical orientations include: solution focused therapy, family systems therapy, play therapy, Eye Movement Desensitization and Reprocessing (EMDR), cognitive behavioral therapy, and Moral Reconation Therapy (MRT). She assists her clients with a variety of emotional, personal, and relational problems. Miki Gordon does not discriminate or refuse professional services to anyone on the basis of race, gender, religion, national origin, or sexual orientation. If your need for services are greater than can be provided in an outpatient practice, Miki Gordon will make a referral for appropriate care. In case of an emergency please call contact 911, your local hospital emergency room, or other local community emergency services.

Confidentiality:

Relationships are built on respect, trust and honesty. Conversations with Miki Gordon will be confidential except in instances where there is a legal mandate to report. These situations are: 1) if you express an intent to harm yourself or someone else and 2) if a child or elderly/disabled adult has been abused or neglected. In addition, a court may order Miki Gordon to testify about your therapy. Also, information may be disclosed to your insurance company in order to obtain reimbursement for services or to determine eligibility or coverage. Miki Gordon will make every effort to inform you regarding any decision pertinent to the confidentiality of the therapeutic relationship.

As part of her work with you, Miki Gordon will enter into your records a diagnosis of your condition. Be aware that this will remain part of your records. If you choose to release this information to your insurance company it will likely become part of your medical record.

Financial Arrangements:

Fees: Miki Gordon is an independent practitioner with Pathways Counseling and Wellness, and charges fees as established by Pathways Counseling and Wellness. A 24-hour notice is required for cancellation of appointments. Pathways Counseling and Wellness reserves the right to bill the client for damages to office facilities caused by willful acts on the part of the client or their minor children.

Complaint procedure:

If you are dissatisfied with any aspect of your treatment please discuss it with Miki Gordon. If you cannot resolve the problem and would like to file a complaint you may contact the North Carolina Board of Licensed Professional Counselors, P.O. Box 21005, Raleigh, NC 27619-1005, (919) 787-1980.

I have read, understand and received a copy of the above disclosure statement and consent to treat.

______Client’s signature Date

______Guardian/Parent Signature Date

______Witness Date Pathways Counseling and Wellness Authorization for Release of Information

Miki Gordon, MA, LPC, NCC 5170 #1 Highway 105 Banner Elk, North Carolina 28604

Name of Client: ______Birthdate: ______

I authorize Miki Gordon and Pathways Counseling and Wellness to contact:

Name of person or agency: ______

Address: ______

Phone: ______Fax: ______

 Release of information to Miki Gordon and Pathways Counseling and Wellness

 Release of information from Miki Gordon and Pathways Counseling and Wellness

 To disclose/request information regarding: history, prognosis, diagnosis, assessments, evaluations, progress, treatment information, and treatment recommendations

 For the purpose of providing, coordinating and managing treatment

 Other (please specify): ______

*I understand that all information received will be treated as protected health information and kept confidential unless I authorize disclosure or when disclosure is otherwise allowed by state or federal law. I may revoke this authorization at any time by signing and dating the Authorization Revocation section below. Upon fulfillment of the above stated purpose(s), this consent will automatically expire after 12 months of signature date. **I understand that federal law prohibits the disclosure of substance abuse information per the confidentiality and disclosure requirements of 42 CFR Part 2. ***I understand that federal law also includes the protection of HIV/AIDS information under G.S. 130A-143.

______Client or Legal Guardian Signature Date Signed

______Relation to Client

______Witness Date Signed

Authorization Revocation

I revoke the above authorization for release of information effective ______. I understand that any actions that were taken on the authorization prior to this date are legal and binding.

______Client or Legal Guardian Signature Date Signed

______Witness Date Signed Disability Rights North Carolina: Champions for Equality and Justice We protect the legal rights of people with disabilities. What We Do • Represent people with disabilities based on our targets and case selection criteria; • Educate people with disabilities about their legal, civil,and service rights; • Investigate complaints about neglect, abuse, and related deaths in institutions; • Provide advice, training, and support for self-advocacy; • Reach out to traditionally underserved ethnic and disability communities; and • Litigate to improve the lives of groups of people with disabilities. The People We Serve Disability Rights NC provides advocacy and legal representation for North Carolinians with disabilities. You could b e eligible for Disability Rights NC services if: • You have a developmental or intellectual disability; • You have a psychiatric or emotional disability; • You are a patient in a state psychiatric hospital; • You have a physical, learning, or sensory disability; or • You have a traumatic brain injury. How We Can Help If you have a disability, Disability Rights NC may be able to help you with: • Abuse, neglect, or violations of your rights in an institution; • Access to technology such as communication devices, power wheelchairs, lifts, or ramps; • Discrimination in housing, transportation, or access to public and private programs and services; • Rights to basic support, personal care, therapy, health care, and other individualized treatment; • Special education rights; • Overcoming barriers to returning to work if you are on SSI/SSDI; or • Voting registration, vote casting, or inaccessible polling places. Our Values We value the dignity of ALL people and their freedom to control their own lives. We work for justice upholding the fundamental rights of people with disabilities to live free from harm in the communities of their choice with the oppo rtunity to participate fully and equally in society. How to Reach Us Visit us online: www.disabilityrightsnc.org Our case criteria is provided on our website. If we cannot be of direct assistance, we will refer you to other sources of help. Call or fax us: 919-856-2195 voice 877-235-4210 voice 888-268-5535 TTY 919-856-2244 fax Se habla español Write to us: Disability Rights North Carolina 2626 Glenwood Avenue, Suite 550 Raleigh, North Carolina 27608 Upon request, information is available in alternate format. Disability Rights North Carolina is a federally mandated protection and adv ocacy system with funding from the U.S. Department of Health and Human Services, the U.S. Department of Education, and the Socia l Security Administration. Disability Rights NC is a 501(c)(3) nonprofit organization.

By signing below, I acknowledge that I have read and understand my disability rights as described above: ______Client Signature Date