Stonebriar Counseling Associates 9741 Preston Road, Suite 208, Frisco, Texas, 75034

704 East 15th Street, #104-106, Plano, Texas, 75074 garybaas@gmail.com

Gary S Baas, MA, LPC (#72178)

Intake & Informed Consent for Services Client Name: Date:

I WELCOME YOU! It is my desire to insure that your participation in counseling is a most productive and satisfying one. In order to facilitate a therapeutic relationship, I have set forth certain information, which will enable you to make an informed consent to counseling.

I hereby give my consent to enter into counseling services with Gary S. Baas, M.A., LPC (#72178) I understand by engaging in counseling with Gary Baas, I agree to the following:

TherapistI have been made aware of my counselor’s qualifications & have chosen to engage in counseling with said counselor. I am aware that my counselor is licensed by the Texas State Board of Examiners of Professional Counselors (License #72178).

Nature of Counseling

While it may not be easy to seek help from a mental health professional, it is hoped that through therapy you will change in the following ways: 1) gain greater insight into your situation and feelings, 2) develop expanded conceptualizations of your life, relationships, circumstances, and future; 3) move toward resolving your concerns; and, 4) forge a life plan that promotes greater realization of your human potential, happiness, and success.As your therapist, using my knowledge of human development and behavior, human change process, and Cognitive Behavioral Therapy, I will make observations about situations as well as suggestions for new ways to approach them. It will be important for you to explore your own feelings and thoughts and to try new approaches in order for change to occur.

Assessment & Evaluation

I understand my first session will be a diagnostic evaluation, in which my counselor will gather personal information for the purpose of determining issues that need to be addressed and recommendations for how to address such issues.I understand my evaluation may result in a diagnosis, if required by my insurance company or other third party payer.I understand my counselor may, at times, utilize testing instruments (i.e. Beck Depression Inventory, Strong’s Inventory Test, etc.) in order to best determine my counseling needs.

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Course of Counseling & Treatment Planning

I understand the number, frequency, & duration of my counseling sessions will be determined based upon my specific needs. I understand that I will collaborate with my counselor to develop a treatment plan & agree to work toward my treatment goals.

Risks of Therapy

Therapy is the Greek word for change. You may learn things about yourself that you do not like. Often, growth cannot occur until you experience and confront issues that induce you to feel sadness, sorrow, anxiety, or pain. The success of our work together depends on the quality of the efforts on both our parts, and the realization that you are responsible for lifestyle choices/changes that may result from therapy. Specifically, one risk of couple’s therapy is the possibility of exercising the dissolution option.

Family Involvement

You may bring other family members to a therapy session if you feel it would be helpful or if recommended by your therapist. I understand I may request family involvement in my counseling & agree to discuss this with my counselor prior to scheduling any such session(s).

Confidentiality & Records

Discussions between a therapist and a client are confidential. No information will be re-leased without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: abuse or neglect of minors; abuse, neglect, or exploitation of the elderly; abuse of patients in mental health facilities (§681.33 TAC, Ch.681); criminal prosecutions (§611.004 Texas Health & Safety Code, Ch. 611); child custody cases (§ 611.006 Texas Health & Safety Code, Ch. 611); situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn or disclose (§ 611.004 Texas Health & Safety Code, Ch. 611); fee disputes between the therapist and the client (§611.006 Texas Health & Safety Code, Ch. 611); or the filing of a complaint with the licensing board (§611.006 Texas Health & Safety Code, Ch. 611). If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this matter further. By signing this information and consent form, you are giving your consent to the undersigned therapist to share confidential information with all persons mandated by law and with the agency that referred you, and you are responsible for providing payment for services rendered, and you are releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this.I understand my counselor will maintain a record of my counseling, which will be kept for 7 years after I terminate counseling if I am an adult. My record will be kept for 7 years past my 18 th

birthday if I am a minor.

Termination of Services

I understand I may choose to terminate counseling at any time & I am aware that my counselor recommends a termination session prior to such termination.

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Incapacity or Death

I acknowledge that, in the event the undersigned therapist become incapacitated or dies, it will become necessary for another therapist to take possession of my file and records. By signing this information and consent form, I give my consent to allowing a licensed mental health professional selected by the undersigned therapist to take possession of my file and records and provide me with copies upon request or to deliver them to a therapist of my choice.

PAYMENT FOR SERVICES/INSURANCE FILING

The financial part of seeking therapy is everyone's (including mine) least favorite part of this process. However, because this is a professional relationship, I have found that it is highly important to make sure that all practical and financial arrangements, agreements, and expectations are made before we get started. Therefore, I ask that all new clients read this carefully, sign it at the bottom of the page, and return it to me by your first appointment. I cannot see a new client(s) until this information is completed.Clients / Parents or Guardians are responsible for payment for all services rendered. Payment or co-payment is expected by the end of the session. I accept cash, check, and most credit cards. There is a $25 fee on all returned checks or credit card charge backs.Except where I have a contractual agreement with an EAP or insurance carrier, my fees are $115.00 for the initial session and $90.00 thereafter.Balances, Any outstanding balances must be paid prior to scheduling an appointment. All balances 30 days or more will be charged to the authorized credit card on file. Late Cancel and No Show appointment may be charged the same day.For uninsured clients, I offer sliding scale application for clients in financial need, this fee is offered after I have evaluated the person's ability to pay. If a client's ability to pay changes, this negotiated fee is subject to also change to give other clients the ability to afford services.For insured clients, I will make fee adjustments according to my contract with an insurance carrier. Any contractually agreed charges that are not paid are the responsibility of the client or responsible party. If I do not have a contract, my full fees will be charged. Anything not paid for by the insurance company is charged to the client or responsible party. I will file a claim for the services rendered to your insurance company that I am a provider. However, please remember, I do not work for any insurance companies. I work for my clients. Accordingly failure on the part of your insurance company to honor any payment agreement, process an authorization request or claim, add unexpected limitations to your policy, etc. leaves you, responsible for any unpaid charges.

I acknowledge & agree to pay Robert Good M.A., ThM., LPC-S, CART, the following fees per each service provided to me by Robert Good (includes co-pays & co-insurances) In so doing, I consent for Robert to provide requested information to my insurance company in order to secure payment from the company for services rendered:

(Initial)Initial Diagnostic Evaluation: $115Individual Session: $90Family/Couples Session: $90

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In the event disclosure of your records or testimony is required by law, payment will be expected from you, regardless of whose attorney subpoenas my involvement. Client records will not be released without written consent, unless court-ordered to do so. Please note: a subpoena does not constitute a court order.

COURT TESTIMONYIf requested to testify or be subpoenaed to appear in court, ______________ requires a minimum fee of $560.00 (4 hour minimum, billed at $130.00 an hour, and $60.00 travel expense), to be paid prior to the court appearance.  If he/she is required to be at court longer than 4 hours, the time will be billed at $130.00 per hour, including partial hours. *** _____ Please initial

Initial Diagnostic Evaluation: $____________________

Individual Session: $_______________

Family/Couples Session: $_________________

____________________________________ __________________Signature of Client/Legal Consenter Date

_________________________________ _________________Signature of Client/Legal Consenter Date

CRISIS SITUATIONS

In the event of a crisis, you may call my personal cell phone at 214-789-7015 and I or my assistant will make every effort to return your call & schedule if necessary. However, please understand that your therapist may be in sessions & unable to return your call until later in the business day. Should you need immediate assistance or experience a crisis after hours or on the weekend, please call 911 or contact the Mobile Crisis Unit at 1-866-260-8000.

DUTY TO WARN/DUTY TO PROTECT

In the event my therapist believes I (or my child if my child is the client) am at risk of harming myself or someone else, I give my permission for my therapist to contact anyone who is in a position to prevent said harm, including the person who is in danger, if applicable. Further, I give my permission for the following persons to be contacted in addition to any law enforcement or medical personnel contacted:

Name: ____________________________ Phone #: __________________________

Name: ____________________________ Phone #: __________________________

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SCHEDULING & CANCELLATIONS (Initial) I agree to attend all of my scheduled sessions & to call at least 24 hours ahead of time if I will not be able to attend my session for any reason. I understand I will be charged the regular session fee ($90) for my session if I cancel less than 24 hours before my scheduled appointment or do not attend my scheduled session without calling. This policy is not meant to be punitive, but appointment times you schedule are reserved for you at the exclusion of others who may be waiting to see the therapist. Insurance cannot and will not be billed for these charges.

I understand my counselor will make every effort to work with my scheduling needs, as possible within my counselor’s schedule & office availability.

Risks of Therapy

Therapy is the Greek word for change. You may learn things about yourself that you do not like. Often, growth cannot occur until you experience and confront issues that induce you to feel sadness, sorrow, anxiety, or pain. The success of our work together depends on the quality of the efforts on both our parts, and the realization that you are responsible for lifestyle choices/changes that may result from therapy. Specifically, one risk of couple’s therapy is the possibility of exercising the dissolution option.

By signing this Client Intake and Consent for Services form, I the undersigned client, acknowledge that I have both read and understand all the terms, conditions, & information contained herein. I have been provided sufficient opportunity to ask questions and seek clarification of anything contained in this agreement that is unclear to me.

____________________________________________________ ________________________Client(s) Signature(s)/Legal Consenter Signature Date

Permission for Professional Services for a Minor:I have the legal authority to seek and grant permission for professional services for a minor child & have provided the counselor with a copy of proof of such authority if applicable,

_______________________________________________, Birth date_______/_______/_______,

_______________________________________________, Birth date_______/_______/_______,

_______________________________________________, Birth date_______/_______/_______,

_______________________________________________, Birth date_______/_______/_______,there being no legal decree disallowing my authority to assume such responsibility.

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_________________________________________________ _____________________________Client/Parent Signature Date

Client Family member signatures: All family members who are involved in this therapy need to sign below, indicating an understanding of these policies and procedures. If you have any questions, please discuss them with your therapist before you sign.

__________________________________________________ _____________________________Client Date

__________________________________________________ _____________________________Client Date

__________________________________________________ _____________________________Client Date

__________________________________________________ _____________________________Client Date

Credit Card InformationPlease provide your credit card information if you plan use to make payments on your account or for no-shows and missed appointments without giving agreed notice:

Type of Credit Card (circle): ••••••Visa•••••• Master Card • ••• • Discover

Name as printed on card: ________________________________________Credit Card Number: ____________________________________________Expiration Date: ___________________________3-4 Digit Security Code on Back of Card: ______________________Billing address for credit card (if different than address already given): ______________________________________________________________

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By my signature below, I grant Gary S. Baas, M.A., LPC. my permission to charge the account described above.Signature Date: _________________________________________________Printed Name: __________________________________________________Optional automatic payment agreementIf you would like your credit card billed monthly for any outstanding balances (including missed appointments, claims not paid, and bounced checks), please sign the permission below.By my signature below, I grant Gary S. Baas, M.A., LPC. permission to charge the account described above for any outstanding balance on a monthly basis.

Signature/Date: __________________________________________________All information disclosed on this form will be held in accordance with Federal Confidentiality Standards

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1Stonebriar Counseling Associates – Gary S. Baas, M.A., LPC

Name: Today’s Date:

Address: Date of Birth:

Age:

City, State, Zip Primary Phone: Race/Ethnicity: Caucasian / African-American /

Hispanic / Asian / Other:

Cell/Work/Alternate Phone: E-mail Address: Marital Status: Single / Married / Divorced /

Widowed

Client Initial Assessment

Your Reason(s) for Coming to Counseling (Please briefly describe below.)

Referral Information

How did you hear about SCA/Gary Baas (who referred you)?

Are you being required to come to counseling by anyone (probation, CPS, etc.)? YES NOIf YES, who?

Your Counseling/Treatment History (Please list any current or past counseling, psychiatric care, or substance abuse treatment.)

Date Provider Problem/Issue Duration Outcome

About Your Family (Please provide the following information. When noting relation, note step-, half-, adoptive, etc.)

Name Age Relation In Home?(Y/N)

Living?(Y/N)

Substance Abuse(Y/N)

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Your School Information (for students only)School Name/Location: Current Grade Level:

Extra-Curricular Activities (i.e., band, sports, FFA, Student Council, Clubs, etc.):

Your Employment InformationEmployer (If unemployed, list most recent employer):

City:

Currently Employed? Yes / No Hours per Week: Position:

Your Spiritual Beliefs/Church InformationDescribe your spiritual beliefs:

Church Membership:Are you active?

Information About Suicide/Self-Harm

Have you ever thought about committing suicide? NO YES When/Explain:

Have you ever attempted suicide or hurt yourself? NO YES When/Explain:

Have you ever known anyone who committed suicide? NO YES When/Explain:

Significant Life Events (Indicate any that apply to you.)

Event/Situation YES or NO When/Who/Other Information

Death of a Parent

Divorce of Parents

Death of a Brother/Sister

Death of Other Family Member

Chronic Illness of Family Member

Multiple Moves

Loss of Good Friend(s)

Abandoned by Parent(s)

Chronic Illness/Hospitalization of Self

Struggles w/Sexual Identity/Orientation

Other:

Information About Abuse You Have Suffered or Witnessed

Emotional - Includes chronic discord between parents, yelling, screaming, cursing. YES NOExplain:

Physical - Includes hitting (w/hands or other object); pushing; withholding food, water, sleep. YES NOExplain:

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Sexual - Includes words, looks, and touching: YES NOExplain:

About Your Substance Use History (Complete the information and circle your drug of choice.)Substance AGE of

First UseDATE ofLast Use

Days Used in Past 30 Days?

Amount Used at a Time

Frequency of Use (How

Often)

Method of Use (smoke, snort, IV,

etc)

Alcohol

Marijuana

Amphetamines / Methamphetamines

Powder Cocaine

Crack Cocaine

Heroin

Other Opiates (Morphine, Methadone, Oxycontin, Hydrocodone, Codeine, Demerol, Dilaudid, Vicodin, Lorcet, Percodan)

Benzodiazapines (Sedatives, Anxiolytics, Xanax, Valium, Soma, Librium, Klonopin, Ambien, Versed, Restoril, Halcion, Sonata, Dalmane)

Ecstasy

GHB, Ketamine

DXM (Corecedin, cough syrup)

PCP

LSD, Mushrooms, or other hallucinogens

Inhalants

Steroids

Tobacco

Other Substances

Your Legal Status

Currently on Probation? YES NO Probation Officer’s Name:

On Probation for: Scheduled end date:

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Arrests in past year: Charges pending:

Charges Pending in Court? YES NO Explain:

Child Protective Services Status

Current CPS Involvement? YES NO CPS Worker’s Name:

If Yes, have your children been removed from the home? YES NO

If Yes, whose care are the children in currently?

If CPS is involved, please describe the circumstances:

Your Interest in Counseling / Treatment

On a scale from 1 to 10, how interested are you in receiving counseling services at this time ?

1 2 3 4 5 6 7 8 9 10 Not at Somewhat Very all interested Interested Interested

Is There Anything Else You Want The Counselor To Know?

Personal Information

Church Membership ___________________________ Are you active? ________

Medical Doctor ____________________________ Medications ______________

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Who referred you?

___ New Life Radio Network ____ Fellowship Church ___ SCA Web Site ___ Pastor (please give name) ____________________ ___ School (please give name) ____________________________________

___ Physician (please give name) __________________________________ ___ Family/Friend (please give name) __________________________________ Yahoo Yellow Pages ____ Allen Community Web Page___ Focus On The Family ____ McKinney Community Web Page

___ Google Search ____ Blue Cross/Blue Shield Web Page

What drew you most to Stonebriar Counseling Associates? ___Church referral ___ Christian Influence ___ Convenient Hours

___ Convenient Location ___ Affordable Cost ___ Personal Referral

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Your Information. Your Rights. Our Responsibilities.This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we’ve shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

Your ChoicesYou have some choices in the way that we use and share information as we:

Tell family and friends about your condition

Provide disaster relief

Include you in a hospital directory

Provide mental health care

Market our services and sell your informationRaise funds

Our Uses and DisclosuresWe may use and share your information as we:

Treat youRun our organizationBill for your servicesHelp with public health and safety issuesDo research

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Comply with the lawRespond to organ and tissue donation requestsWork with a medical examiner or funeral directorAddress workers’ compensation, law enforcement, and other government requestsRespond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).

Get a copy of this privacy noticeYou can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.Choose someone to act for you

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If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1.You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your careShare information in a disaster relief situationInclude your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes

Sale of your information

Most sharing of psychotherapy notes

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.Treat you

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We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: "http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html"www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease

Helping with product recalls

Reporting adverse reactions to medications

Reporting suspected abuse, neglect, or domestic violence

Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

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We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claimFor law enforcement purposes or with a law enforcement official

With health oversight agencies for activities authorized by law

For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our ResponsibilitiesWe are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.We must follow the duties and privacy practices described in this notice and give you a copy of it.

We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: "http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html"www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this NoticeWe can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.

EFFECTIVE DATE: SEPTEMBER 23, 2013

Bob Good, LPC-S 704 East 15th Street, #104 Plano, Texas, 7507

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We never market or sell personal information. We will never share any treatment records without your written permission.I HAVE READ AND UNDERSTAND THE HIPAA POLICIES LISTED ABOVE.

______________________________________ _____________

PRINT NAME DATE

______________________________________ _____________

SIGNED NAME DATE

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