Integrity Counseling & Coaching CLIENT INFORMATION FORM NAME: _______________________________________________________________ DATE: ______________________ ADDRESS: _________________________________________ CITY:_______________________ZIP: _______________ HOME #_______________________WORK #: _____________________CELL #: _______________________________ MAY WE LEAVE DISCREET MESSAGES AS NEEDED AT ABOVE LISTED NUMBERS? YES________NO_______ EMAIL ADDRESS: SOCIAL SECURITY NUMBER:

MAY WE CONTACT YOU AT THIS ADDRESS? YES ___ NO___ DOB: ______________ AGE: ________

NAME AND NUMBER OF EMERGENCY CONTACT PERSON: ___________________________________________ HOW DID YOU HEAR ABOUT INTEGRITY COUNSELING? ______________________________________________ BRIEFLY DESCRIBE THE ISSUES/PROBLEMS THAT LED YOU TO SEEK THERAPY TODAY: ________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ WHAT GOALS WOULD YOU LIKE TO ACHIEVE IN THERAPY? __________________________________________

DESCRIBE ANY HEALTH PROBLEMS, MEDICAL CONDITIONS, OR RECENT OPERATIONS:

___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ALLERGIES: _______________________________________________________________________________________ LIST ALL MEDICATIONS YOU ARE TAKING:__________________________________________________________ ___________________________________________________________________________________________________ LIST YOUR PHYSICIAN(S) NAME(S):_________________________________________________________________ LIST ANY PAST PSYCHOLOGICAL/PSYCHIATRIC/ COUNSELING/TREATMENT YOU HAVE HAD: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ HOW OFTEN DO YOU DRINK ALCOHOL? ______________________ IS THERE ALCOHOLISM IN YOUR FAMILY? _________________________________________________________________________________________ WHAT ILLICIT DRUGS HAVE YOU USED?_____________________________________________________________ DO YOU BELIEVE YOU HAVE, OR HAD AT ANY TIME IN THE PAST, A PROBLEM WITH ALCOHOL OR EXPLAIN: ___________________________________________________________________ DRUGS? IS THERE ANYTHING ELSE WE SHOULD KNOW? _____________________________________________________

Integrity Counseling & Coaching FINANCIAL POLICY Full payment is due at time of service (unless prior arrangements have been made). Please feel free to ask if you have any questions about our financial policy. Understanding our financial policy is important to our relationship. Insurance is a contract between you and your insurance company. We will file your claim to your insurance company or provide you with the proper information needed for you to file a claim. You are responsible for the timely payment of your Account. We will send information, including clinical information i.e. diagnosis, to your insurance company unless you specifically instruct us not to do so. We will send information electronically, so please read the HIPPA notice. Uncollected balances may be turned over for collection or reported to the state’s attorney’s office. CANCELLATION POLICY Please help us to serve you and others better by keeping your scheduled appointments. If you need to cancel or reschedule, please give us as much notice as possible so we can offer that time to someone else. Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal counseling session. This will be billed to you. We may require prepayment in order to schedule a subsequent appointment CONFIDENTIALITY Federal and State laws protect your confidentiality (See 42 U.S.C. 290dd-3 and 290ee-3 for Federal laws and 42 CFR Part 2, 491.0147 FL). Your counselor will not share information with any person outside of Integrity Counseling, Inc. without your written permission, except as required by law or as needed to file your insurance claim. Information obtained from minors is not generally shared with parents without permission. Exceptions to Confidentiality: Federal regulations do not protect from disclosure of information related to a client’s involvement in a crime against property or personnel. We are required under State law to report suspected abuse of a child, elderly person, or individual with a disability. We may share limited information in the event of a medical emergency or in the event of a specialized court order signed by a judge. Your counselor has the option of breeching confidentiality if you report a specific plan or intent to cause serious bodily harm to an identifiable person. HIPPA (Health Insurance Portability and Accountability Act) laws allow you access to your file and protect the electronic transfer of information. CONSENT TO TREATMENT I am voluntarily seeking outpatient counseling at Integrity Counseling & Coaching. I understand that I have rights and responsibilities regarding my participation in treatment, including the right to discontinue therapy. I am strongly encouraged to discuss my treatment plan and status in treatment with my counselor. Counselors will also discuss alternatives, procedures, qualifications, and drawbacks to therapy. With my signature below, I acknowledge that I have read, understand, and agree to all of the above. I also acknowledge that I have been given a copy of HIPPA/Privacy Practices implemented here at Integrity. Individual counseling sessions are intended to be 45-50 minutes in length. Please note: We do not provide emergency services. In true crisis call 911.

__________________________________________________ Date:_________________ Signature of Client and/or Legal Guardian

We will show up for your appointment, and we expect that you will also. If you need to cancel or reschedule any appointments, please give us as much notice as possible so we can offer that appointment time to someone else.

You will be charged $60.00 for individual appointments not cancelled 24 hours in advance.

Signature

Date

INTEGRITY COUNSELING & COACHING 1501 S. Belcher Road, Suite B-4 Largo, FL 33771 (727) 531-7988

CONSENT FOR INTEGRITY COUNSELING & COACHING TO RELEASE CONFIDENTIAL INFORMATION ABOUT DUI DOB:

I, (client name)

(Date of Birth)

HEREBY AUTHORIZE: Integrity Counseling & Coaching inc. its therapists and its representatives. TO RELEASE TO THE FOLLOWING SPECIFIED PERSON OR AGENCIES: Suncoast Safety Council (727) 442-0233 fax (727) 447-1677 Probation Officer or Court Representative if applicable Other: THE FOLLOWING INFORMATION: Results of evaluation including recommendations and urinalysis drug screen (abstinence) results. Records substantiating treatment including compliance with treatment recommendations and abstinence status including subsequent drug tests, discharge information such as discharge summary and after treatment plan. FOR THE PURPOSE OF: Compliance with DUI/ PROBATION. We MUST notify Suncoast Safety Council and Probation of Positive Drug Tests.

I UNDERSTAND THAT THIS CONSENT TO OBTAIN CONFIDENTIAL INFORMATION IS SUBJECT TO REVOCATION BY ME, EXCEPT TO THAT ACTION WHICH HAS BEEN TAKEN IN RELAINCE THEREON AND UNLESS OTHERWISE STATED, THIS CONSENT SHALL HAVE A DURATION NO LONGER THAN THAT NECESSARY TO EFFECTUATE THE PURPOSE FOR WHICH IT IS GIVEN One year from the date signed.

CLIENT SIGNATURE:_____________________________________

DATE:

GURDIAN SIGNATURE:___________________________________

DATE:

WITNESSESED BY: _______________________________________ DATE:

CONFIDENTIALITY NOTICE “THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL REGULATIONS (42 CFR PART 2) AND PROHIBITS YOU FROM MAKING ANY FURTHER DISCLOSURE OF IT WITHOUT SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IS NOT SUFFICIENT FOR THIS PURPOSE.”

Reports will be sent either by US mail or electronically via FAX or E-mail. We will provide you with free copies of customary reports. If you want us to mail or fax these reports, there is a $5.00 fee. By initialing here, I give permission to fax information to the above agencies.

What do you know about being referred here?

What do you think about being referred here?

List three of your strengths that will help you complete this.

List three of your shortcomings or weaknesses that could be challenging to your completing this.

What do you spend most of your time each week doing? (Other than work)

Next Next

Who do you spend your time with?

What are your living arrangements (what kind of dwelling, who do you live with, do you rent-own…?)

What is your annual income?

What is your current spiritual/ religious/ values orientation?

As long as you are coming here, what goals would you like to achieve?

Name of Employer: Dates of Employment: Begin Date:

Weekly Pay: Termination Date:

Job Duties: Reason for Leaving: Did alcohol or drug use ever contribute to …? (Put a checkmark next to all that ever applied) Has your use ever contributed to… Has your use ever contributed to… Being absent from work Being late to work or left work early Being terminated or asked to leave Disciplinary action of any kind Being less friendly or social at work Being less productive or successful Any other impact (please explain): Name of Employer: Dates of Employment: Begin Date:

Weekly Pay: Termination Date:

Job Duties: Reason for Leaving: Did alcohol or drug use ever contribute to …? (Put a checkmark next to all that ever applied) Has your use ever contributed to… Has your use ever contributed to… Being absent from work Being late to work or left work early Being terminated or asked to leave Disciplinary action of any kind Being less friendly or social at work Being less productive or successful Any other impact (please explain): Name of Employer: Dates of Employment: Begin Date:

Weekly Pay: Termination Date:

Job Duties: Reason for Leaving: Did alcohol or drug use ever contribute to …? (Put a checkmark next to all that ever applied) Has your use ever contributed to… Has your use ever contributed to… Being absent from work Being late to work or left work early Being terminated or asked to leave Disciplinary action of any kind Being less friendly or social at work Being less productive or successful Any other impact (please explain): Name of Employer: Dates of Employment: Begin Date:

Weekly Pay: Termination Date:

Job Duties: Reason for Leaving: Did alcohol or drug use ever contribute to …? (Put a checkmark next to all that ever applied) Has your use ever contributed to… Has your use ever contributed to… Being absent from work Being late to work or left work early Being terminated or asked to leave Disciplinary action of any kind Being less friendly or social at work Being less productive or successful Any other impact (please explain):

CLIENT RIGHTS 1. I understand I have the right to treatment, and that I am voluntarily seeking services. 2. I have the right to individual privacy and respect. My addiction or other problems do not diminish my intrinsic worth as a human being. 3. There will not be any prejudicial treatment as a result of age, sex, race, religion, or cultural background. 4. I have the right to know my diagnosis, evaluation, goal of treatment, and the methods recommended to attain this goal. In fact, I will be involved in establishing my treatment goals. 5. If I am not satisfied in any way with answers or treatment given, I have the right and responsibility to discuss these with the Director. 6. I understand my right to confidentiality includes the following: a. b. c. d. e.

That my presence in therapy is not to be disclosed to anyone without my permission. No portion of my clinical records may be disclosed to anyone without my permission. That my condition, progress, or any other information concerning me may not be disclosed to anyone without my permission. By law, all suspected cases of child, disabled, or elder abuse/neglect must be reported to the Department of Children & Families. Therapist is required to warn individuals whose lives are known to be in danger.

7. I have the right to report client abuse by calling 1-800-962-2873.

CLIENT EXPECTATIONS 1. Maintain regular and consistent attendance. 2. Show evidence of motivation to change and to participate. 3. Remain alcohol and drug free, or work at a specifically developed Responsible Drinking Treatment Plan. 4. Treatment will be extended if unable to maintain abstinence or comply with other treatment expectations. YOU ARE RESPONSIBLE TO MEET THE TIME DEADLINES ON YOUR TREATMENT PLAN. 5. For D.U.I. related substance abuse counseling you are expected to: A) Attend counseling regularly B) Go to self-help meetings C) Stay sober

6. Be responsible for payment at time of services. 7. Integrity provides free copies of customary reports- mailed or faxed copies are $5.00 up to 5 pages, and $1.00 per page thereafter. 8. Generally accepted hygiene practices are encouraged and a copy of infection control policies is available. 9. There shall be no violence or threats of physical violence in group settings. 10. Other individuals’confidentiality must be respected. No discussion of other individuals outside the group setting is acceptable. 11. These rules were designed to foster the safety and trust necessary for a positive therapeutic environment. 12. Prescription drug use must be reported and verified by your prescribing doctor.

Client signature:________________________________________ Date:___________

Medical History Name

Date

General How would you describe your current health? Do you have any medical concerns? Are you receiving any medical treatment? What type? When was your last physical examination? Do you have any allergies? What? Has your health been effected in any way by your use of drugs including alcohol?

Do you or have you had any of the following mark “x” for yes: Anemia___ Anxiety___ Bleeding___ Breathing/Lung Problems___ Bowel/Stomach Trouble___

Convulsions/Seizures____ Depression___ Diabetes____

Headaches___ Head injury___

Heart/Blood Pressure___ Kidney Problems___ Liver Trouble___ OB/GYN Problems___ Pancreatitis___

List all medications you are taking and the prescribing doctor/ ARNP’S

If you are taking mood or mind altering prescription drugs your prescribing doctor/ARNP will be notified of your participation in treatment and their input will be invited. This is for the protection & benefit of all of us If you test positive for prescription drugs with out a legal prescription, this will be seen as abuse of drugs

Emotional Have you had any changes in eating? _____ sleeping? _____ Explain Have you experienced periods of tearfulness? _____ sadness? ____ loss of interest in activities? _____ Periods of hopelessness? ____ Do you ever think of suicide? ____ harming yourself? ____ others?____ Do you experience difficulty with fearfulness? _____worry too much? ____have trouble concentrating?_ Do you have trouble controlling your temper?_____ explain

Substance abusing individuals are at higher risk for contracting HIV/AIDS, Hepatitis, Tuberculosis, sexually transmitted diseases (STD’s) as well as other communicable diseases. We encourage you to get accurate information and anonymous/confidential testing. We will gladly help you get anonymous/ confidential testing and treatment - there are good assistance programs available. Please ask! (Continued on Next Page)

Our licensing by The Department of Children and Families requires us to do both screening and education about communicable diseases. New cases must be reported to The Department of Health. We ask people to practice courtesy and general good hygiene including universal precautions and seeing a doctor when sick. A copy of our infection control policy is available to you. We will gladly answer questions you may have. Hepatitis is a disease of the liver. There are several types of Hepatitis and people who are infected may not know it because they don’t have symptoms yet. Chronic Hepatitis B & C are two of the most serious types which can be life threatening. Early detection can help save lives because treatment is available. Hepatitis can be transmitted through body fluids such as blood, semen, and vaginal fluids. Most commonly these fluids are exchanged during sexual contact, by piercing & tattooing, or by sharing paraphernalia used to smoke, snort, or shoot drugs. Hepatitis is also transmitted by contact with fecal stool, which is the reason for the signs in restaurant bathrooms. It is generally accepted that Hepatitis is not spread by casual contact. Testing is available through your doctor or at the Health department. Symptoms of Hepatitis include tiredness or fatigue, flu-like symptoms, loss of appetite, nausea, vomiting, fever, and weakness. You can protect yourself from exposure by abstaining from sex and drug use. Safer sex and not sharing paraphernalia reduce exposure risks. We have handouts that provide additional information. HIV (Human Immunodeficiency Virus) is the virus that causes AIDS (Acquired Immunodeficiency Syndrome). People with HIV/AIDS may look healthy. Again early detection can lead to life preserving and life enhancing treatment. HIV/AIDS can be transmitted through body fluids such as blood, semen, vaginal fluid, and sometimes breast milk. It is transmittable through oral, anal, and vaginal sex. It is transmittable through the sharing of needles including those used for drugs, piercing, and tattooing. HIV/AIDS is not spread through casual contact. Anonymous testing is available at the Health Department. Symptoms of AIDS often do not occur for many years after infection with HIV, and the infected person is contagious during this time. Again testing can save the lives of others as well as help the infected person receive proper treatment. You can protect yourself from exposure by abstaining from sex and use of needles. Safer sex including avoiding high-risk behavior reduces exposure risks. We have handouts available for more information. Tuberculosis is a disease spread from person to person through germs in the air. Tuberculosis usually affects the lungs, but can affect other organs. More powerful strains of Tuberculosis are showing up and infection is on the increase. There are higher risk situations including exposure to confined spaces such as institutions or planes. Testing is available through your doctor or at the Health Department. Symptoms of Tuberculosis include feeling sick or weak, weight loss, fever, night sweats, cough, coughing up blood, and chest pain. We ask that people practice coughing into their elbow. For a demonstration or for additional information, please ask.

Screening Have you ever?

Do you have?

Shared a needle? Had a tattoo or piercing? Had sex with a prostitute? Had sex for money or drugs? Had unprotected sex outside a monogamous relationship? Had multiple sex partners in the past year? Had a STD? Had a blackout while drinking using other drugs? Had sex with someone who would answer yes to any of the questions?

Night sweats? Fatigue? Flu-like symptoms? Cough? Cough up blood? Fever? Have you had? A recent HIV test? A recent Hepatitis test? A recent Tuberculosis test?

Risk Level Low Medium High

For anonymous/confidential testing call the Pinellas County Health department @ (727) 824-6911

SIGNATURE

DATE

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential; so please be honest. Place an X in one box that best describes your answer to each question. Date:

Name: Questions 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 5 or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected of you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

0

1

2 2 to 4 times a month

3 2 to 3 times a week

4 4 or more times a week

Never

Monthly or less

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

Never

Less than monthly

Monthly

Weekly

Never

Less than monthly

Monthly

Weekly

Never

Less than monthly

Monthly

Weekly

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

Daily or almost daily Daily or almost daily Daily or almost daily

No

Yes, but not in the last year

Yes, during the last year

No

Yes, but not in the last year

Yes, during the last year Total

-World Health Organization