Intake (Minors)

Counseling Services

All forms or letters that are requested by our clients to be completed by our clinical professionals will be charged at the clinician's full session rate. If your session goes over the allotted time there will be an overcharge of $50 per every 15-minutes. There is a $50 returned check fee for any payment returned by your bank.

Initials

Our office requires a 24-hour notice prior to canceling or rescheduling an appointment. To avoid a full session charge for a late cancellation or missed appointment, please contact us 24-hours before the scheduled session.

Initials

Psychoeducational Testing:
$3,500 (This cost may not be reimbursed by your insurance provider)

ADHD, Autism Spectrum Disorder, Dyslexia, Learning Disabilities

Testing fee covers 4-6 hours of testing, testing results session, 504 Plan/IEP, advocacy campus visit, & test report with diagnosis (when applicable), along with clinical & educational recommendations.

Records and Confidentiality:
Your mental health record is accessible to you within 15 business days of your written request. A fee of $45.00 will be charged for the first 25 pages of the record and additional pages will be at a rate of $1.00 per page.

Initials

Court attendance and testimonies:

We are not trained custody counselors nor are we expert witnesses.

However, if you chose to engage us in a legal matter, there is a non-refundable retainer fee of $2,500 due at the time the subpoena is received by FHC. The retainer is used for a court appearance ($250/hr) to block out time to attend and prepare for your court date - whether we are called on the stand or not or the court case is cancelled.

If the amount of time in court surpasses the single day appearance covered by the prepaid retainer, you will be charged at the agreed upon $250/hourly rate. Additional time spent preparing for ANY attorney’s requests including but not limited to: preparing the release of client records, any notarization costs, interviews, responding to ANY attorney’s emails or phone calls at the $250 hourly rate.

Additionally, if a subpoena is issued to our company for ANY legal matter, you agree to accept and assume financial responsibility for the payment of the $2,500 retainer fee and your primary payment method will be charged at the time we receive the subpoena.

Initials

Electronic Communication:

If you would like to speak with your therapist before your next scheduled session, please contact the office to set up a telehealth (phone/ZOOM) or in-person session (normal session rate applies).

Initials

Thank you for choosing to begin your care at Forever Hope Counseling & Educational Services, LLC….

Client Signature / Legal Guardian

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

LIMITS OF CONFIDENTIALITY

Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a client (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances

Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

Minors/Guardianship

Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

By signing below, I agree to the above limits of confidentiality and understand their meanings and ramifications.

Client Signature / Legal Guardian

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEATLH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Effective date: July 8, 2014

Forever Hope Counseling & Educational Services, LLC will only release information in accordance with state and federal laws and the ethics of the counseling profession.

This notice describes Forever Hope Counseling & Educational Services, LLC’s policies related to the use and disclosure of the client’s healthcare information. Use and disclosure of protected health information for the purposes of providing services. Providing treatment services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

TREATMENT:

Provide, manage, coordinate care with other healthcare professionals.

You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to your mental health professional and your insurance company, if applicable.

Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA.
Special Instructions for completing the authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes”. All Psychotherapy Notes recorded on any medium (i.e., paper, electronic) by a mental health professional (such as a psychologist or a psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and are separate the rest of the individual’s medical records. Excluded from “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

My signature indicates I understand HIPAA Authorizations and a separate mental health information disclosure form must be signed to grant permission to discuss protected client information.

Client Signature / Legal Guardian

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Debit/Credit Card Authorization

Forever Hope Counseling requires a credit card on file to secure services with our therapists. Please inform the front desk before your sessions begin if you have a preference to pay with cash or check.

Name on the card:

Type of Card:

Visa

MasterCard

Discover

American Express

Card Number:

Expiration Date:

Security Code:

Billing Address:

Zip Code:

Phone Number:

Email address:

By signing this form, you authorize FOREVER HOPE COUNSELING & EDUCATIONAL SERVICES, LLC to charge this card for clinical, academic, behavioral, or testing services provided for –

Client Name:

This card will be charged for any fees related to these services such as: missed appointments or same-day cancellations.

We are unable to schedule appointments with your therapist if there is a balance on your account.

Cardholder Signature:

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Informed Consent for Teletherapy Services

The following information is provided to clients who are seeking Teletherapy services. This document covers your rights, risks and benefits associated with receiving services, my policies, and your authorization. Please read this document carefully, note any questions you would like to discuss before you agree to sign.

Teletherapy Services Defined:

Teletherapy Services means the remote delivering of any form of counseling services via technology-assisted media. This includes a wide array of clinical services and various forms of technology that include, but is not limited to, video, internet, a smartphone, tablet, PC desktop system or other electronic means. The delivery method must be secured by two-way encryption to be considered secure. Synchronous (at the same time) secure video conferencing is the preferred method of service delivery.

Limitations of Teletherapy Services:

While Teletherapy Services offer several advantages such as convenience and flexibility, it is an alternative form of therapy, or adjunct to therapy, and thus may involve disadvantages and limitations. For example, there may be a disruption to the service (e.g. phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction.

Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, your counselor might not see various details such as facial expressions. Or if audio quality is lacking, they might not hear differences in your tone of voice that they could easily pick up if you were in their office.

Additionally, your therapist’s office decreases the likelihood of interruptions. However, there are ways to minimize interruptions and maximize privacy and effectiveness. Your therapist will take every precaution to ensure technologically secure and environmentally private sessions.

Interactive Video, Electronic Medical Record, Secure Email for Documents: Forever Hope Counseling uses JITUZU and or ZOOM for interactive video, which complies with HIPAA standards requiring 256-bit AES encryption.

Client Responsibilities for Teletherapy Services:

The virtual sessions can only be conducted while the client is within the state of TEXAS.
The virtual sessions must be conducted on a Wi-Fi or ethernet (not mobile) network for the best connections and to minimize disruption.
Only communicate through a device that you know is safe and technologically secure (e.g. has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.) Do not use “auto-remember” names and passwords.
If you conduct a Teletherapy session at your place of employment, make sure you have checked your company’s policy before using a work computer for personal communication.
As the client, you are responsible for finding a private, quiet location where the sessions may be conducted.

Sessions are not able to take place if other individuals are present in your location.

Your therapist is required to verify your identity and location at the start of each session.

In Case of Technology Failure:

Teletherapy sessions could encounter a technological failure. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, PLEASE call the office at (210) 490-9062. You must have access to the phone that your therapist has so you can be reached. In addition, your session may need to be rescheduled, if there are problems with connectivity.

I AGREE TO THE FOLLOWING:

I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location. I understand I am solely responsible for maintaining the strict confidentiality of my user ID, password, and/or connectivity link. I shall not allow another person to use my user ID or connectivity link to access services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversations.

Initials

I understand that there will be no recording of any of the online sessions and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.I agree to take full responsibility for the security of any communications or treatment on my own computer or electronic device and in my own physical location. I understand I am solely responsible for maintaining the strict confidentiality of my user ID, password, and/or connectivity link. I shall not allow another person to use my user ID or connectivity link to access services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversations.

Initials

Consent for Teletherapy Services Treatment:

I voluntarily agree to receive online therapy, parent, couples or family therapy services including an assessment, continued care, treatment, and/or other services and furthermore authorize FOREVER HOPE COUNSELING & EDUCATIONAL SERVICES, LLC to provide such care, treatment or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive at any time. By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

Initials

Client Signature / Legal Guardian

By typing name above, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Date

Client Information -

Please answer all of the following or complete as much as possible .

Today's Date

Referred By

First name

Last name

Main area(s) of concern

Date of birth

Age

Primary phone number

Address (where the child lives)

Zip Code

May we communicate by email? If yes, please provide your email address:

Yes

Email:

Who does the child live with? (check all that apply)

Mother

Father

Step-mother

Step-father

Other - Legal Guardian

Do you have the right to bring your child in for counseling?

Yes No

Parent / Guardian Information

Name

Phone Number

Specify if:

Biological

Step

Guardian

Adoptive

Occupation

Work Phone Number

Address (if different from above)

Name

Phone Number

Specify if:

Biological

Step

Guardian

Adoptive

Occupation

Work Phone Number

Address (if different from above)

Emergency Contact

First & Last Name

Phone Number

Relationship to client

Please list all names and ages of people living in your home:

Has your child ever received any type of mental health services? (psychotherapy, counseling, medication, psychiatric services)

Yes No

If yes, please specify:

Previous Therapist's Name

Previous Therapist's Phone Number

Was previous counseling successful?

Yes

Is your child currently taking any medications? If yes, please list prescription medications they are currently taking:

Yes No

Medications

About how long has your child been on these medications?

Prescribing Physician's Name

Prescribing Physician's Phone Number

Prescribing Physician's Address

When was your child's last wellness visit with their PCP or general Physician?

Physician's name:

List any medical conditions below:

Does your child complain of pains, stomachaches, headaches, or tiredness?

Yes

If yes, please specify:

Has your child had any of the following?

Childhood Illnesses

Allergies

Injuries

Other

None

If yes, please specify:

Developmental Milestones -
Please specify whether developmental milestones were on-time or delayed.

Eating Bottle or breast fed

on-time

delayed

Sat up

on-time

delayed

Sleeping habits

on-time

delayed

Crawled

on-time

delayed

Walked

on-time

delayed

Smiled

on-time

delayed

Used complete sentences

on-time

delayed

Learned to ride a bike

on-time

delayed

Pregnancy

Was your child a planned pregnancy?

Yes

Natural or C-section?

Natural

C-section

Weeks of gestation:

Please list any delivery or developmental complications:

Biological Family Mental Health History

If yes, please specify:

Describe your child's sleep routine:

Describe your child's eating habits:

Education Background

Please inform us of your child's schooling history:

Day Care - Name of school

Elementary School - Name of school & grade(s) attended

Middle School - Name of school & grade(s) attended

High School - Name of school & grade(s) attended

Has your child ever had to repeat a grade?

Yes

If yes, please specify:

Has your child ever been suspended or expelled from school?

Yes

If yes, please specify:

Does your child currently have an IEP or 504 from his/her school? If yes, please provide a copy for their file.

Yes

Please check any of the following related services that apply to your child:

IEP

504

Speech

Social & Peer Development Skills

Is your child struggling academically, behaviorally, or socially in school? If yes, please specify:

Yes

Details:

On average, how long does it take your child to finish homework? Are there any learning disabilities?

Does your child play video games?

Yes

What game ratings do you allow your child to play?

Does your child engage in social media

Yes

Which social media websites?

Does your child spend time outdoors?

Yes

How much time does your child spend on electronics in a week?

Does your child struggle with limits and boundaries?

Yes

If yes, please specify:

Does your child use the internet without supervision?

Yes

What safeguards are you taking regarding explicit exposures via internet?

What chores and responsibilities does your child have at home?

Does your child have difficulty making friends?

Yes

How many close friends would you say your child has?

Does your child have difficulty communicating or socializing with others?

Does your child seem to enjoy things other children their age enjoy?

Yes

Is your child heavily interested in a particular topic or activity?

Does your child have repetitve behaviors or rituals they focus on daily?

Yes

If yes, please specify

Does your child struggle with understanding social cues?

Yes

If yes, please specify

Has your child ever imposed self-injury?

Yes

Has your child ever experienced:

Suicidal thinking

Hallucinations

Drug / Alcohol abuse

Bullying

Parenting

In a few sentences, please describe your relationship with your child:

What are your methods of discipline regarding your child?

Grounding

Spanking

Lectures

Yelling

Taking away privileges

Ignoring

Natural consequences

Other

If other, please specify:

Are you open and willing to learn new and effective strategies in handling difficult behaviors?

Yes

If yes, please specify:

Has your child ever mistreated animals?

Yes

If yes, please specify:

What is your family's faith or spiritual belief?

Would you like prayer to be incorporated in your child's sessions?

Yes

I don't know

What do you do well as a parent?

What do you consider to be your child's strengths?

What does your child need help with in their development?

Please list any significant life changes or stressful events that have occurred in the past two years such as: marriage, divorce, new baby, financial instability, domestic violence, moving, new school, loss, etc...

Do you own any weapons?

Yes

If yes, how do you keep the weapons secure and away from minors in the home?

Abuse

Has your child experienced abuse or neglect? (physical abuse, sexual abuse, verbal abuse)

Yes

I don't know

If yes, please specify:

What would you like your child to gain from therapy or what areas would you like to be addressed in sessions?

Please explain any other details you would like to share:

Your information will be encrypted.