Intake (Couples)

Counseling Expectations:

Our goal is to partner with our clients and their families in achieving their goals. Communication is key. Challenge yourself by being prepared for sessions and using your time efficiently by arriving on time, exploring insights or choices made during time away from your therapist.

All clients begin services on a weekly basis to gain momentum in developing support and building a therapeutic alliance with their therapist. As progress is reviewed, the frequency of appointments may then be scheduled on a bi-monthly and monthly basis once desired progress has been achieved. All clients have the autonomy in changing the frequency as needed.

Minors:

Family or parent sessions are scheduled monthly but can be more frequent, if necessary or requested. For safety reasons, a responsible adult with permission to speak to the therapist must accompany the minor and wait in the waiting room in case there is a need to speak to the adult during the session. Parent sessions are a time to share progress, exchange updates, and gain valuable insight and strategies. Our parents work collaboratively with their child’s therapists.

Please inform our office of any changes in child custody. We require legal updates as they occur.

Counseling Services:

Other charges:

There is a $50 returned check fee for payments returned by your bank.
We charge a clinician’s full rate to complete forms or letters for you, when requested. All forms and letters must be within our scope of practice. Your therapist will inform you if your request can be completed.
Counseling session time overages are charged $50 per every 15 minutes.

Late Cancellations/Missed appointments:

We require a 24-hour notice prior to canceling or rescheduling an appointment. We value your time as well as the time of our counselors. On rare occasions, we may request to reschedule our appointment and will do our best to honor a 24-hour notice. Illnesses and scheduling conflicts may occur from time to time; however, to avoid a full session charge for a late cancellation or missed appointment, please contact us 24 hours before the scheduled session.

Initials

Psychoeducational Diagnostic Testing: $3,500

(In Texas, trained and qualified LPCs can administer appropriate autism assessments though the cost for evaluation may not be reimbursed by your insurance, who may require an evaluation be performed by a licensed physician. Texas state law mandates coverage for autism treatment, but the reimbursement process is complex and has specific rules depending on your insurance plan. We encourage our clients to contact their insurance providers for specific reimbursement information before scheduling their testing with our office.)

There is a $3500 cost for formal evaluations designed to diagnosis ADHD, autism spectrum, and or Dyslexia with Dr. Sandra Salazar.

Your test fee includes a campus observation (when allowed), testing sessions, results session, creation of a 504 Plan/IEP, advocacy campus visit (within San Antonio) during the same school year, and a test report with diagnosis, if applicable. Your test report also includes necessary clinical and educational recommendations.

Records and Confidentiality:

Your mental health record is accessible to you within 10 business days of your written request. You can find our form on our website, and it can be submitted online. 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.

Court attendance and testimonies:

We are not trained custody counselors nor are we expert witnesses. We request not be summoned to court; however, if you chose to engage us in a legal matter, there is a non-refundable retainer fee of $3,500 due at the time the subpoena is received. The retainer fee is allocated to a court appearance whether we are called on the stand or not. There are no refunds or credits resulting from a cancelled court date, etc. If the amount of time in court surpasses the single day appearance covered by the prepaid retainer, there is a $275/hourly rate for time spent preparing for attorney’s requests.

You agree that you will be charged for our clinicians to prepare the release of client records, any notarization costs, interviews, respond to attorney’s emails or phone calls at the $275 hourly rate.

Initials

You understand and agree that if a subpoena is issued to Forever Hope Counseling for ANY legal matter, you agree to accept and assume financial responsibility for the payment of the $3,500 retainer fee and your primary payment method will be charged at the time we receive the subpoena.

Initials

Weapons Safety Clause

We are committed to providing a safe, secure, and welcoming environment. For the safety of all clients, clinicians and staff, weapons of any kind are strictly prohibited on these premises, regardless of licensure or permit. Bringing weapons, firearms, explosives, or dangerous materials of any kind onto our property is strictly prohibited. Violation of this policy will result in the immediate termination of services and refusal of entry.

Initials

Electronic Communication:

We are committed to providing a safe, nonjudgmental, and confidential therapeutic environment for you and your family. Please be aware that all communication via email, text messages, and other electronic means limit your privacy and will increase the chances of your personal information being shared with others.

Social Media:

To avoid dual relationships, please respect the privacy of our counselors on all social media platforms. FHC counselors cannot befriend you since this violates our ethical codes. If it is discovered that your counselor has accidentally connected with you online, your FHC counselor will discontinue that social connection and reserves the right to cancel the counseling relationship and refer you to outside our office.

Our clinicians do not communicate by text or email.

Please use your best judgement and reserve all calls for times you are unable to wait until your next session. 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

Graduate Students

Forever Hope Counseling & Educational Services has partnered with The University of Texas at San Antonio (UTSA) to provide training opportunities for graduate associates. These graduate associates are completing practicum and internship requirements for their graduation under the supervision of Dr. Sandra Salazar (Site Supervisor) and a UTSA faculty advisor. Graduate Associates have also been carefully selected and trained to join our clinical team. As part of their clinical training, they participate in observing sessions, attending our clinical meetings, performing research, and providing counseling to clients. Please note you will be given the option to decline observations or services by our graduate associates.

Initials

MEDICAID/MEDICARE

YOU acknowledge WE are accepting YOU strictly as a private-pay patient.
YOU understand that WE are a non-participating provider with Texas Medicaid and WE do not submit claims to the state.
YOU understand that no claims will be filed to Medicaid by our office.
YOU explicitly accept full direct financial responsibility for all session charges.
YOU understand WE cannot provide YOU with a superbill by our office for reimbursement purposes.

Termination of Services:

As you make progress and have met your goals, a time will come to celebrate your progress and end our services. We will be excited for you, however, there may be other reasons to terminate our services.

You may choose to end our therapeutic relationship at any point for any reason. We will be respectful of your decision.
For ethical reasons, if there is a lack of progress in your therapy, your therapist may request to end your services. An outside referral to another provider may be more appropriate for your needs.
If a client harasses or is abusive to our staff or clinicians for any reason, we will end our services.
If a client arrives intoxicated or under the influence of a substance, we will not be able to provide services that day and may need to address legal or safety issues, which may also include referring you to alternate services.
If you miss/cancel two consecutive sessions, your therapist may remove you from their schedule and offer a referral for a therapist available outside of our practice. Please discuss any necessary changes in frequency of your sessions with your therapist.

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

The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology.

Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint. Please call 1-800-821-3205 for more information.

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:

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. In the event your card is declined, you agree to offer an alternative credit card or pay cash or check.

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.

Informed Consent for Teletherapy Services

Forever Hope Counseling uses a business ZOOM subscription for interactive video, which complies with HIPAA standards requiring 256-bit AES encryption for Interactive Videos, Electronic Medical Records, and Secure Email for Documents.

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.

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.

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 as much as possible.

Today's Date

Referred By

First name

Last name

Phone number

Main area(s) of concern

Date of birth

Age

Address

Zip Code

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

Yes

Email:

Your Occupation

Highest Level of Education

Marital Status

Single Married Separated Divorced Remarried Widowed

Spouse's Information

First Name

Last Name

Age

Phone Number

Occupation

Address (if different from above)

Highest Level of Education

Emergency Contact

First & Last Name

Phone Number

Relationship to client

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

Are there currently any significant life changes or stressful events that have occured in the past two years such as: marriage, divorce, new baby, financial instability, domestic violence, moving, new job, loss...?

Have you ever received counseling? If yes, please include previous therapist's information below:

Yes No

Previous Therapist's Name

Previous Therapist's Phone Number

Previous Therapist's Address

Have you ever received psychiatric medications? If yes, please list prescription medications that you are currently taking:

Yes No

Medications:

Previous diagnosis? If yes, please provide below

Prescribing Physician's Name

Prescribing Physician's Phone Number

Prescribing Physician's Address

When was your last wellness checkup with your PCP or general Physician?

Physician's Name:

List any medical conditions below:

Medical Background

How would you rate your current physical health?

Poor

Fair

Good

Excellent

How much do you exercise per week?

None

1-2 hours

3 hours +

How many alcoholic beverages do you consume in a week?

None

1-2

3-4

How many hours do you usually sleep most nights?

Do you or your spouse have any concerns regarding addictive behaviors or patterns that impact the marriage or relationship? (gambling, substances, alcohol, any other behaviors or patterns)

Has there been any behavior in your relationship where you or another person has harmed, controlled, or intimidated the other? Please select all that apply -

Slapping, hitting, punching, or kicking

Throwing objects at or near another person

Grabbing, pushing, or restraining someone

Threatening harm to a person, children, pets, or property

Verbal abuse, including yelling, name-calling, or intimidation

Controlling behavior (e.g., monitoring movements, restricting access to money, isolating from family/friends)

None of the above

Have you had a loss in appetite? If yes, please specify:

Yes

Details:

Are you experiencing grief, sadness, or depression? If yes, please specify:

Yes

Details:

Are you experiencing anxiety, panic, or phobias? If yes, please specify:

Yes

Details:

Are you experiencing acute or chronic pain? If yes, please specify:

Yes

Details:

Do you have any sexual concerns?

menopause

andropause

diminished libido

high sex drive

painful intercourse

health issues effecting sex life

infidelity

Other

None

Do you have any sexual concerns regarding your health, happiness, or satisfaction?

Please explain any details related to your physical health history:

How long have you been in this relationship?

What is your level of commitment to this relationship?

(Least) 1

5 (Most)

Why is your current relationship important to you?

What are the concerns that brought you here today?

What concerns do you have with your current relationship?

Frequency of Arguments

How often do you argue with your spouse/significant other?

(rarely/once a month) 1

5 (almost daily)

Please list the strengths of your relationship?

How do you respond to conflict in your relationship?

Have you previously been in therapy?

Yes

If yes, for what issue(s), for how long, and what were the results?

What worked well in addressing your concerns at that time?

Were there aspects of therapy that did not seem effective for you?

What are your suggested goals in counseling?

Is there physical, emotional, or verbal abuse in the relationship? With children?

Have either you or your spouse/significant other discussed separation or divorce?

Have either of you or your spouse/significant other consulted a lawyer?

Is there an ongoing affair?

Is there a past affair?

Are you in a stable, satisfying job?

Are you able to financially afford your current lifestyle?

Do you consider yourself spiritual or religious?

Do you own any weapons? If yes, please specify:

If you have weapons in the home, how do you keep them secured and away from children?

Describe your support system:

What are some of your views, beliefs, and values regarding sexual intimacy?

What other information would you like to share?

We are glad you are here! We look forward to accompanying you along this journey of marital/relationship enhancement!

Your information will be encrypted.