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New Adult Client Information

Paul D. Myers Licensed Mental Health Therapist

New Adult Client Information

Date_______________

Name(s)___________________________________   Age_______ Date of Birth______________

Address:__________________________________City:___________Zip:_________________

Mandatory credit card number to keep on file:________________________________

Expiration date ________ CVC code_________ Zip:___________

Gender: M  F                         Birth Order: Oldest    Middle     Youngest

Occupation:_____________________________

Best Phone Number to Reach You:_______-_________-____________

Marital status:  Married   Single   Divorced (How many times)________

Children (Names/Ages):__________________________________________________________

Family of Origin History:       Age               Occupation                                         Relationship

Father______________________________________________________                   +    –

Mother_____________________________________________________                   +    –

Stepfather___________________________________________________                              +    –

Stepmother__________________________________________________                              +    –

Siblings(ages)________________________________________________                   +    –

____________________________________________________________

Are you currently seeing a Counselor?  Y    N

Previous Counseling (who and when):______________________________________

Church Background:______________________________________________

Current Religious Beliefs:___________________________________________

Chief Complaint: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Stressors (circle any that apply): Family of origin,    Spouse,    Kids,    School,   Work,    Finances,               Past problems,   Friends,     Abuse,   Trauma,    Unexpected Circumstance,     Loss,    Drug use,     Alcohol abuse,     Addictions

Others:_______________________________________________________________________

When did your symptoms start:_________________________________________________

Current Medications:____________________________________________________________

 

The information above is true and accurate and I,__________________________________ give Paul Myers permission to have access to this knowledge.

Paul D. Myers M.A. LPC

Licensed Professional Counselor

Hope Works Counseling

2001 Plano Parkway, Suite 1400 Plano, Texas 75075

 

Qualifications: My educational background consists of a masters degree in the art of counseling as well as a bachelors in psychology. Both degrees were received from Dallas Baptist University. I have experience working with adults, children, adolescence, and families struggling with a variety of emotional and behavioral concerns. I have worked with survivors of abuse, family and marital difficulties, parenting struggles, and mental health conditions including depression, anxiety, and bipolar as well as career counseling. I currently specialize in individual therapy for youth and adults as well as relational/marital counseling.

Counseling Relationship: During our counseling relationship, we will direct our mutual efforts toward agreed upon goals determined on an individual basis. Sessions will last approximately 45-50 minutes. Although sessions may be very personal, ethical guidelines dictate that the relationship between you and I is professional, rather than a social one. If I see you in public, I will protect your confidentiality by acknowledging you only if you approach me first. Services are by appointment only and you are responsible for keeping your appointments and arriving on time. In the event that you cannot keep an appointment, it is your responsibility to call the office at least 24 hours in advance to cancel or reschedule. If you cancel your appointment within the 24 hours prior to the session or do not show up to your scheduled appointment, your credit card on file will be immediately charged for the full hourly fee.

While benefits are expected from the relationship, specific results are not guaranteed. Counseling is a personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or understanding of yourself. Some of these changes cannot be predicted. Together we will work to achieve the best results for you. You have the responsibility to notify me of any other ongoing mental health relationship.

If you are seeing another mental health professional, then permission must first be granted by the first therapist to proceed with a secondary counseling relationship. During the course of this relationship, if you choose to seek counseling elsewhere, you have

the responsibility to terminate this counseling relationship before being seen by another mental health professional.

We may utilize email as a means of communication or in the case of emergencies you may call me. but it is important to understand the parameters of this medium. If you wish to engage in therapy over the phone you will be responsible for paying the normal hourly fee. There may also be times where I receive, but do not respond to your emails or messages. It’s not personal, I will respond if I believe it is appropriate and/or necessary. My lack of response does not indicate a lack of interest. Nothing is more important to me than the well being of my clients so I will get back to you.

 

Referrals: Should you or I believe that a referral is needed, I will provide some alternatives including program and/or people who may be available to assist you. A verbal exploration of alternatives to counseling will also be made available upon request. You will be responsible for contacting and evaluating those referrals. In the event that you have a mental health emergency, you may wish to call CONTACT (a 24-hour crisis line) at 972-233-2233 or 911 for more comprehensive immediate care.

 

Records and Confidentiality: All of our communication becomes part of the clinical record. Adult client records are disposed of five years after the file is closed. Minor client records are disposed of 5 years after the client’s

18th birthday. In the case of my incapacitation or death, you would be contacted by one of my colleagues, who would handle your records and care, as needed. Almost all of our communication is confidential, but the following limitations and exceptions do exist:

  • If I determine that you are a danger to yourself or someone else
  • In the cases of abuse, neglect, or exploitation of a child or elderly adult
  • If you disclose sexual contact with another health professional
  • If I am court ordered/subpoenaed to disclose information
  • If you direct me to release your records
  • In the case of billing or collection of fees
  • I am otherwise required by law to disclose information

Fees: Counseling is an investment toward your overall health. The fee is $120 per session and generally last anywhere from forty five to fifty minutes. The first session may include a general assessment or MSE to help form the best possible treatment solution. This session allows time for the gathering of valuable information and for the completion of paperwork. If there is a need for crisis counseling or other specific needs that require an extended session length, the fee will be equivalent to a two hour slot. These sessions may last up to two hours and a fee of $180.00 will be required for the total extended session. If at any time you have financial concerns, do not hesitate to discuss them with me. In most cases, financial concerns can be resolved.

Payment is expected in full at the time of service, but I will then provide you with a receipt with the appropriate coding, so that you may then file for out-of-network reimbursement through your insurance provider. Some health insurance companies will reimburse clients for counseling services and some will not.  In addition, most will require that a diagnosis of a mental-health condition and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement.

My fee for court appearances, related travel, and preparation is $200 per hour. If I am subpoenaed to testify on your behalf, then I will block out a 4 hour portion (unless I am notified that I will be required to stay longer) of my work day. If your hearing is rescheduled, it is your responsibility to notify me at least 72 hours in advance, so that I may re-book those appointments. If you fail to notify me within the appropriate time frame, you will be billed for that block of time. Fees will be billed and are expected to be paid within 48 hours of the court appearance. You are responsible for any legal fees I incur as related to your case (litigation issues, lack of payment, etc.).

I accept check, cash, and/or credit cards for payment.

I reserve the right to suspend services if there is an unpaid balance on your account.