Child and Family Therapy Intake Packet

8/12/2019 Child and Family Therapy Intake Packet

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2/14Laura McCarthy, PhD, LMFT, PLLC

Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite 407Lakewood, CO 80235720-384-4696DISCLOSURE, TREATMENT, AND FEE AGREEMENT

Degrees and Credentials:Ph.D. in Marriage and Family Counseling (2006)M.Ed. and Ed.S. in Marriage and Family Counseling (2002)Licensed Marriage and Family Therapist #854

Regulation of Psychotherapy Practice:

The Colorado State Department of Regulatory Agencies regulates the practice of psychotherapy for licensedand unlicensed psychotherapists. Concerns regarding the practice of psychotherapy may be directed to theDepartment of Regulatory Agencies, Mental Health Section, 1560 Broadway, Suite #1350, Denver, Colorado80202, (303) 894-7766.

Client Rights and Important Information:

Method of Treatment: You may receive information about the methods of treatment, techniques used,duration of therapy if known, and the fee structure. At any time, you may seek a second opinion or terminatetreatment. Please be advised that in a professional relationship, sexual intimacy is never appropriate andshould be reported to the Department of Regulatory Agencies.

Sessions and Fees: Individual sessions are 45 minutes in length, and are billed at $90 per session (initialevaluation session is $120). Couples or family sessions of 60 minutes in length and are billed at $120 persession (initial evaluation session is $120). Couples sessions of 90 minutes in length are billed at $150 persession. Payment for each session is due at the time of each therapy session. If you carry behavioral health

insurance, arrangements can be made for payment of services from the insurance company and you will beheld responsible for deductibles, co-payments, non-covered services, and/or unpaid balances. You will bebilled $45 for missed sessions unless you cancel at least 24 hours prior to your scheduled session. There is a$30 processing fee for checks returned for non-sufficient funds. *If I am required to appear in a legalproceeding for a current or former client, there will be a $500 flat fee assessed for the appearance and anycorrespondence required with attorneys or others. This fee is due prior to the appearance, and is due even ifthe appearance is canceled for any reason and at any time.

Confidentiality: Sessions are confidential. Information regarding treatment may be shared with a third partyonly with written consent from the client. Exceptions to confidentiality include when the client is inimminent danger of harming self or others, when child abuse or neglect is suspected, or when disclosure is

court ordered. In the case of working with minors, legal guardians will know about the treatment, thoughprivacy will be respected as much as possible. When treating couples and/or families, confidentiality amongfamily members is not a guarantee.

Emergencies: In a mental health emergency, dial 911 or go to your nearest urgent care or emergency center.Non-emergency calls will be returned by the therapist within 1 business day.


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Regarding Divorce and Custody Litigation:If you are involved in divorce or custody litigation, my role as atherapist is not to make recommendations to the court concerning custody or parenting issues. By signingthis Disclosure Statement, you agree not to subpoena me to court for testimony or for disclosure of treatmentinformation in such litigation; and you agree not to request that I write any reports to the court or to yourattorney, making recommendations concerning custody. The court can appoint professionals, who have noprior relationship with family members, to conduct an investigation or evaluation and to makerecommendations to the court concerning parental responsibilities or parenting time in the best interests of

the family's children.

I understand and agree to the conditions stated above, including policies regarding fees, insurance,

cancellations, confidentiality, crisis coverage, and client rights.

____________________________________________ ________________Client or Parent/Guardian Signature Date


____________________________________________ ________________Signature of Witness Date


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Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite #407

Lakewood, CO 80235720-384-4696

CONSENT FOR TREATMENT OF MINORS

Child's Name:_______________________________________________________

Child's Date of Birth:_________________

In the state of Colorado, one biological parent may consent to their child's mental health treatment if the

biological parents are married. If the child's biological parents are separated or divorced, both parentsusually must consent to their child's mental health treatment. An exception would be if the court assigned all

medical decision-making rights to only one of the parents. (This may be different from who has "custody" or

with whom the child resides.) Additionally, both biological parents may have the right to review the child'srecords. Step-parents may not consent to the child's mental health treatment.

Please review your custody agreement, and speak to me if you have questions about who will need to consentto treatment. Please check one of the following:

The childs biological parents are married. (One or both parents may sign.)

One of the childs biological parents is deceased.

The childs biological parents are not married, or are separated or divorced. (Both biological

parents must sign, unless the court granted all medical decision-making rights to only one of

the parents.)

A legal guardian has medical decision-making rights for the child.

I/We _______________________________________________________________ am/are the legal

custodial parent(s)/guardian(s) of _____________________________________ and give permission to

Laura McCarthy, PhD, LMFT to provide psychological services and/or family therapy to my/our child.

____________________________________________ ________________

Signature of Parent Date

____________________________________________ ________________Signature of Parent Date


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Laura McCarthy, PhD, LMFT, PLLC

Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite 407Lakewood, CO 80235720-384-4696CONFIDENTIALITY IN COUPLES AND FAMILY THERAPY

This written policy is intended to inform you, the participants in therapy, that when I agree to treat a couple or afamily, I consider that couple or family (the treatment unit) to be the patient. For instance, if there is a request for thetreatment records of the couple or the family, I will seek the authorization of all members of the treatment unit before Irelease confidential information to third parties. Also, if my records are subpoenaed, I will assert the psychotherapist-

patient privilege on behalf of the patient (treatment unit).

During the course of my work with a couple or a family, I may see a smaller part of the treatment unit (e.g., anindividual or two siblings) for one or more sessions. These sessions should be seen by you as a part of the work that Iam doing with the family or the couple, unless otherwise indicated. If you are involved in one or more of such sessions

with me, please understand that generally these sessions are confidential in the sense that I will not release anyconfidential information to a third party unless I am required by law to do so or unless I have your writtenauthorization. In fact, since those sessions can and should be considered a part of the treatment of the couple or family,

I would also seek the authorization of the other individuals in the treatment unit before releasing confidentialinformation to a third party.

However, I may need to share information learned in an individual session (or a session with only a portion of thetreatment unit being present) with the entire treatment unit that is, the family or the couple, if I am to effectivelyserve the unit being treated. I will use my best judgment as to whether, when, and to what extent I will makedisclosures to the treatment unit, and will also, if appropriate, first give the individual or the smaller part of the

treatment unit being seen the opportunity to make the disclosure .Thus, if you feel it necessary to talk about mattersthat you absolutely want to be shared with no one, you might want to consult with an individual therapist who can treatyou individually.

This no secrets policy is intended to allow me to continue to treat the couple or family by preventing, to the extent

possible, a conflict of interest to arise where an individuals interests may not be consistent with the interests of theunit being treated. For instance, information learned in the course of an individual session may be relevant or evenessential to the proper treatment of the couple or the family. If I am not free to exercise my clinical judgment regardingthe need to bring this information to the family or the couple during their therapy, I might be placed in a situationwhere I will have to terminate treatment of the couple or the family. This policy is intended to prevent the need for

such a termination.

We, the members of the _______________________________________________(couple/family or other unit beingseen), acknowledge by our individual signatures below, that each of us has read this policy, that we understand it, that

we have had an opportunity to discuss its contents with Laura McCarthy, PhD, LMFT, and that we enter couple/familytherapy in agreement with this policy.

________________________________________ ________________Client or Parent/Guardian Signature Date

________________________________________ ________________

Client or Parent/Guardian Signature Date


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Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite 407Lakewood, CO 80235720-384-4696NOTICE OF PRIVACY PRACTICES

In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), this noticedescribes how health information about you is protected, and also how it may be used and disclosed. During

the process of providing services, Laura McCarthy, PhD, LMFT, will obtain, record, and use mental health

and medical information about you that is protected health information. Ordinarily, that information isconfidential and will not be used or disclosed except as described below. Colorado law provides strict

protections for patient confidentiality, which together with ethical restrictions and standards often will be

more private than HIPAA guidelines. This notice takes effect on February 1, 2011 and will remain in effect

until it is replaced.

USES, DISCLOSURES, AND COMMUNICATION OF PROTECTED INFORMATION

A. General Uses and Disclosures Not Requiring the Patient's Consent:1. Treatment: Treatment refers to the provision, coordination, or management of health care

(including mental health care) and related services. During treatment, the provider may consult withother providers, without identifying you by name and also not disclosing any other identifying

information about you, in order to ensure the best care possible for your concerns.

2. Payment: Payment refers to the activities undertaken by the provider to obtain or provide

reimbursement for the provision of health care. For example, the provider will use your informationto develop accounts receivable information, to bill you, and (with your consent) to bill third parties. If

you elect to have a third party pay for your treatment, the information provided to the third party may

include information that identifies you as well as your diagnosis, type of service, date of service, andother information about your condition and treatment. A medical biller works with the provider to

provide confidential billing services.3. Contacting the Patient: The provider may contact you to remind you of appointments, or tochange or cancel appointments. The provider may leave messages on voicemail or with other parties,

identifying the name and phone number of the provider. The provider will use best judgment in the

details left on a voicemail. If you do not want the provider leaving messages, or if you wish to restrictthe messages in any way, please notify the provider in writing.

4. Required by Law: The provider will disclose protected health information when required by law

or necessary for health care oversight. This includes, but may not be limited to: (a) reporting

suspected child abuse or neglect; (b) when court ordered to release information; (c) when there is alegal duty to warn or take action regarding imminent danger to others; (d) when the patients is a

danger to self or others or gravely disabled; (e) when a coroner is investigating the patient's death.

5. Family Members: Except for certain minors, protected health information cannot be provided tofamily members without the patient's consent. In situations where family members are present during

a discussion with the patient, and it can be reasonably inferred from the circumstances that the patient

does not object, information may be disclosed in the course of that discussion. However, if the patientobjects, protected health information will not be disclosed.

6. Emergencies: In life-threatening emergencies, the provider will disclose information necessary to

avoid serious harm or death.


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B. Patient Authorization or Release of Information: The provider may not use or disclose information inany other way without a signed authorization or release of information. When you sign an authorization

or a release of information, it may later be revoked provided that the revocation is in writing. The

revocation will apply, except to the extent the provider has already taken action in reliance thereon.

C. Alternative Means of Receiving Confidential Information You have the right to request that you

receive communications of protected health information from the provider by alternative means or at

alternative locations. For example, if you do not want the provider to mail statements or other materialsto your home, you can request that this information be sent to another address. There are limitations tothe granting of such requests. You will also have to pay any additional costs that may be associated with

such a request.

Protection of Confidential Information: The provider has taken steps to protect the confidentiality of your

information, including the use of name-codes, password protection of computer files, locked file cabinets,

and other security measures. Your files will be destroyed (shredded or incinerated) when past the timerequired for the maintenance of such records. If you have further questions, please contact the Privacy

Officer, Laura McCarthy at 720-384-4696.

I hereby acknowledge that I have received a copy of the provider's Notice of Privacy Rights.

________________________________________ ________________Client or Parent/Guardian Signature Date

________________________________________ ________________

Client or Parent/Guardian Signature Date


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Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite 407Lakewood, CO 80235720-384-4696MISSED APPOINTMENT/LATE CANCELLATIONS CHARGES

By signing below, I acknowledge that I am responsible for payment of charges by Laura McCarthy, PhD,LMFT for missing an appointment without at least 24-hour notice of cancellation. I acknowledge that theamount for which I am responsible in the event of a late-canceled or missed appointment is $45.00. I agree topay this amount within 30 days of my late-canceled or missed appointment. I understand that my healthinsurance will not be responsible for payment of any missed appointments.

(I understand that emergencies, bad weather, and scheduling conflicts do have the potential to interfere withour scheduled appointments. I allow for one missed appointment or late cancellation without charge. After

that, I must request the missed appointment/late cancellation fee.)




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Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite #407

Lakewood, CO 80235720-384-4696

CLIENT INFORMATION FORM FOR CHILDREN/ADOLESCENTS

Client Name: Date of Birth: Gender: M F

Street Address: City/State/Zip:

Legal Guardians Name: Relationship to Child:______________________


(Please circle or star your preferred phone number)

Home Phone: Messages okay? Y or N

Work Phone: Messages okay? Y or N

Cell/Other Phone: Messages okay? Y or N

Email address: Ok to send email? Y or N

May I email you my newsletter with articles and tips that may provide additional help? (Your confidentiality will be protected, and

your information will never be given to a third party.) Y or N

Childs Natural Mothers Information: Name:_______________________________________________

Street Address: Same as above or: City/State/Zip:

Phone:______________________________________________

Childs Natural Fathers Information: Name:_______________________________________________

Street Address: Same as above or: City/State/Zip:

Emergency Contact Name: Relationship:

Emergency Contact Phone Numbers:

Name(s) of Step-Parent(s) (if applicable):_________________________________________________________________________

Names and Ages of Siblings (if applicablePlease include step-siblings, half-siblings, etc.):________________________________

__________________________________________________________________________________________________________

School Child Attends:____________________________________________________ Grade:__________

Does your child have an Individual Education Plan (IEP)? Y or N

Does your family identify with a religious or spiritual community?________________________________________________

Please list a few of your childs strengths:________________________________________________________________________

__________________________________________________________________________________________________________

Please list a few of your strengths as a family:______________________________________________________________________

__________________________________________________________________________________________________________

Phone:_______________________________________________


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Please check any current symptoms your child or adolescent is experiencing:

____Depression/Sadness ____Isolation/Withdrawal ____Frequent Suicidal Thoughts

____Aggression/Violence ____Frequent Homicidal Thoughts ____Anxiety/Panic/Worry

____Appetite Problems ____Impulse Control Difficulty ____Phobia/Fear

____Sleep Disturbance ____Difficulty Expressing Feelings ____Obsessions and/or Compulsions

____Anger/Irritability ____Victim of Abuse ____Low Self-Esteem/Confidence

____Relationship Conflicts ____Perpetrator of Abuse ____Problems Thinking/Concentrating

____Communication/Trust Problems ____Addictive Behavior ____Pronounced Mood Swings

____Grief/Loss ____Alcohol/Substance Abuse ____Stress/Feeling Overwhelmed

____Chronic Medical Problems ____Separation Anxiety ____Legal/Financial Problems

____Binging/Purging ____Blended Family Issues ____Sex-Role/Gender Questioning

____Tantrums ____Bed Wetting or Soiling Issues ____Night Terrors

____Inattention ____Hyperactive ____Oppositional Behavior

____Lying/Manipulative Behavior ____Issues around Divorce/Separation ____Destruction of Property

____Fire Setting ____Risk Taking Behavior ____Stealing

____Running Away ____School Problems or Truancy ____Had Difficult Birth/Pregnancy

____Animal Abuse ____Struggles with Social Skills ____Attachment/Bonding Difficulties

Has your child/adolescent experienced any traumatic events? Y or N If so, please describe:____________________________

__________________________________________________________________________________________________________

Has your child/adolescent witnessed significantly heated parental arguments? Y or N

Indicate any Current Medications and Dosage:_____________________________________________________________________

Name and Phone Number of Prescribing Professional:_______________________________________________________________

If not on medication, is a referral for a medication evaluation needed? Yes No Maybe

Please list any current physical health concerns:____________________________________________________________________

__________________________________________________________________________________________________________

Please list past and present tobacco, alcohol, and drug use:___________________________________________________________

__________________________________________________________________________________________________________

Who referred you to see me?______________________________ (e.g., friend, name of doctor, name of website, etc.)

What concern brings you in? What goals do you hope to achieve through counseling? _____________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Has your child/adolescent participated in therapy before? If so, what was helpful and/or unhelpful about the experience? If not, what

hopes and/or reservations about therapy do you or your child have?____________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________

How do you feel therapy for your child/adolescent can be most helpful? Do you or your child have thoughts or preferences about

how you would like therapy to proceed? _________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Thank you for taking the time to complete this information!


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Client Name: Date of Birth: Gender: M F


(Please circle or star your preferred phone number)

Home Phone: Messages okay? Y or N

Work Phone: Messages okay? Y or N

Cell/Other Phone: Messages okay? Y or N

Email address: Ok to send email? Y or N

May I email you my newsletter with articles and tips that may provide additional help? (Your confidentiality will be protected, and your

information will never be given to a third party.) Y or N

Emergency Contact Name: Relationship:

Emergency Contact Phone Numbers:

Marital Status: Never Married Married (# of yrs _____) Committed Relationship Separated Divorced Widowe

Occupation:_________________________________________________________

Please check any current symptoms you are experiencing:

____Depression/Sadness ____Isolation/Withdrawal ____Frequent Suicidal Thoughts

____Aggression/Violence ____Frequent Homicidal Thoughts ____Anxiety/Panic/Worry

____Appetite Problems ____Impulse Control Difficulty ____Phobia/Fear

____Sleep Disturbance ____Difficulty Expressing Feelings ____Obsessions and/or Compulsions

____Anger/Irritability ____Victim of Abuse ____Low Self-Esteem/Confidence

____Domestic Violence ____Perpetrator of Abuse ____Problems Thinking/Concentrating

____Relationship Conflicts ____Addictive Behavior ____Pronounced Mood Swings

____Workplace Stress ____Alcohol/Substance Abuse ____Stress/Feeling Overwhelmed

____Communication/Trust Problems ____Grief/Loss ____Legal/Financial Problems

____Chronic Medical Problems ____Parenting Issues ____Religious/Spiritual Issues

____Binging/Purging ____Sexual/Intimacy Issues ____Sex-Role/Gender Questioning

Indicate any Current Medications:_______________________________________________________________________________

Name and Phone Number of Prescribing Professional:_______________________________________________________________

If not on medication, is a referral for a medication evaluation needed? Yes No Maybe

Please list any current physical health concerns:____________________________________________________________________

__________________________________________________________________________________________________________

Please list past and present tobacco, alcohol, and drug use:____________________________________________________________

__________________________________________________________________________________________________________

Laura McCarthy, PhD, LMFT7220 West Jefferson Avenue, Suite 407Lakewood, CO 80235720-384-4696CLIENT INFORM TION FORM FOR DULTS


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Who referred you to see me?______________________________ (e.g., friend, name of doctor, name of website, etc.)

What concern brings you in? What goals do you hope to achieve through counseling? _____________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Have you participated in therapy before? If so, what was helpful and/or unhelpful about the experience? If not, what are your hopes

and/or reservations about therapy? ______________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

How do you feel our therapy together can be most helpful? Do you have thoughts or preferences about how you would like therapy

to proceed? _________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Thank you for taking the time to complete this information!


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Licensed for personal use only

Child Outcome Rating Scale (CORS)

Name _____________________________________________

Date: ________________________Who is filling out this form? Please check one: Child_______ Caretaker_______

How are you doing? How are things going in your life? Please make a mark on the scale tolet us know. The closer to the smiley face, the better things are. The closer to the frowny

face, things are not so good.If you are a caretaker filling out this form,please fill out

according to how you think the child is doing.

Me

(How am I doing?)I------------------------------------------------------------------------------------I

Family(How are things in my family?)

I------------------------------------------------------------------------------------I

School(How am I doing at school?)

I------------------------------------------------------------------------------------I

Everything(How is everything going?)

I------------------------------------------------------------------------------------I

International Center for Clinical Excellence

2003, Barry L. Duncan, Scott D. Miller, & Jacqueline A. Sparks


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Licensed for personal use only

Outcome Rating Scale (ORS)

Name _____________________________________________

Date: ________________________

Who is filling out this form? Please check one: Self_______ Other_______If other, what is your relationship to this person? ____________________________

Looking back over the last week, including today, help me understand how you have beenfeeling by rating how well you have been doing in the following areas of your life, where

marks to the left represent low levels and marks to the right indicate high levels. If you are

filling out this form for another person,please fill out according to how you think he or she

is doing.

Individually(Personal well-being)

I----------------------------------------------------------------------I

Interpersonally(Family, close relationships)

I----------------------------------------------------------------------I

Socially(Work, school, friendships)

I----------------------------------------------------------------------I

Overall(General sense of well-being)

I----------------------------------------------------------------------I

International Center for Clinical Excellence

2000, Scott D. Miller and Barry L. Duncan

Documents

Child and Family Therapy Intake Packet