NEW CLIENT PAPERWORK FOR  BRIGITTA LALONE, LCSW-R                                        Page 1 of 5
Please complete and read each page, sign where indicated on page 5. If in doubt about signing anything or if you have any questions, I will be happy to discuss them with you in the session.
________________________________________________________________________________________________________________________________
Today’s Date _____/______/______ Your Name __________________________________ Sex : M F Age ___
Date of Birth _____/______/______ SS# ____ - ____ - ____ Who referred you?______________Phone______ 
Street Address _______________________ Apt# _____ City ______________ State ____ Zip Code ________
Home Ph ( ) ________ - _________ Work Ph ( ) ________ - _________ Cell Ph ( ) ________ - __________
Please tell me if it is NOT okay to call you at any of the above numbers. I will not disclose the nature of our relationship.
Email address (will be kept confidential )______________________________ Email is used only for administrative purposes. Email cannot be used for canceling appointments or as a means of therapy.

Names and ages of other people living in the home _____________________________________________
Emergency contact ______________________________ Hm ( ) _______ - _________ Wk ( ) _____ - _______

Employer _________________ Position/Title ______________ How long employed by this co.?__________
Insurance Information (if applicable)
Name of Company under which claim to be filed __________________Member ID# ______________________
Group/Policy # ___________ Co-payment amount $ _________ Deductible amount if applicable $ __________

Information regarding the Primary Insured (if different from the client)
Name of Primary Insured _____________________ Relationship to you __________ Date of Birth_ __/___/___
SS# of Primary Insured ________- _______- _________ Employer of Primary Insured ____________________
Reason you are seeking help today? _________________________________________________________

Circle the symptoms and /or areas of your life affected by the problems that bring you here today:

Mood  Anxiety  Sleeping Habits   Eating Habits   Physical symptoms  Concentration problems  Temper Problems

Marriage/Partner  Other Relationships  Job/School Performance  Financial Problems     Legal Problems     Other

List any current or chronic medical  conditions_________________________________________________
List any prescription and over the counter drugs/vitamins, herbs, taken in the last 90 days.
_____________________ dosage _______ # of times per day ______ prescribed by _____________________
_____________________ dosage _______ # of times per day ______ prescribed by _____________________
_____________________ dosage _______ # of times per day ______ prescribed by _____________________
List medical providers you have seen in the last 90 days _________________________________________
List any allergies __________________________________________________________________________

Primary Physician Name and phone# : _____________________ Do you have a psychiatrist also? Yes No
Circle other drugs you have used in the past 90 days:  Alcohol     Caffeine     Nicotine    Marijuana    Cocaine Heroin     Pain Pills     Inhalants      Amphetamines/Speed       Ecstasy       LSD            Other
Have you ever had any type of counseling before? ____ yes ____ no. If yes, what year/s? _________________
Reason? __________________________How long? ___________ Reason for ending?___________________
Have you ever been hospitalized for emotional of mental reasons, including substance abuse rehab? _____yes ______ no Year _____ Reason ______________________ Year ______Reason ________________________
Is there a history of alcohol or drug use in your family? _______________________ Has a friend, partner or relative discussed concerns about your use? ______________ Have you ever been concerned about your drinking or other drug use? ___________

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CONSENT FOR TREATMENT
Thank you for selecting me as your counselor. The intent of this form is to inform you about the basic treatment relationship between counselor and client, to inform you of basic policies and to help ensure that you understand our professional relationship.

COUNSELING PHILOSOPHY, EXPECTATIONS OF CLIENTS:
I believe strongly in the capacity of people to help their selves and I see our counseling relationship as one in which you are in charge of setting your own goals and I am privileged to travel with you as you work toward attaining your goals. I expect that you will be involved in the counseling process and that you understand that I will work with you, not for you. My approach to therapy is basically a holistic one: we will discuss your issues from many perspectives and examine the effects on you; relationships; and any other areas that may be meaningful to you.  Your decision to choose to enter counseling is a voluntary one and you may terminate it at any time without penalty.  If, in my professional opinion, it is in your best interest to refer you to another therapist, I will do so because ethical standards dictate this course of action. I will provide you with names and numbers of therapists for you to contact, if you wish. Whether you choose to continue counseling with another therapist is entirely your decision. Please note that it is impossible to guarantee any specific results regarding your counseling goals. However, we will work together to achieve the best possible results for you. Sessions are 50 minutes in length unless specified in advance. By signing this consent, you agree to begin a counseling relationship. A copy of this informed consent will be provided, and I will be considered your therapist. This relationship will be in effect until termination occurs or until I have not seen you in session for more than 4 weeks from the date of our last scheduled session unless you and I have a prior agreement to leave your case open for a specified amount of time. (see pg 4, under Termination)

SCOPE OF PRACTICE, EMERGENCY CONTACT:
I operate an outpatient private practice, and offer individual, family, couples and group therapy. I do not have an emergency practice. Clients are assumed to be self-responsible, autonomous, functioning individuals who are not in need of day to day supervision. I return routine client calls received during office hours within 48 hours. If it is a Friday afternoon or a weekend your 48 hour period begins on the following Monday. On occasion, there may be an unavoidable delay; I appreciate your understanding in this circumstance. When I am out of the office for an extended period of time I will leave detailed information on my voicemail about when I will be returning phone calls. 

IN THE EVENT OF AN EMERGENCY:
You can receive 24 hour assistance at Newark Wayne Community Hospital. You may also call Lifeline at 1-800-310-1160.  If you experience a life or death emergency, you should immediately call 911 or go to your nearest hospital emergency room. 

INDIVIDUAL AND COUPLES CONFIDENTIALITY
When I am working with individuals, the individual holds the right to confidentiality. When I am working with couples, I am obligated to preserve confidentiality on behalf of the couple. This means that I will not release information about either member of the couple without the consent of both. This also means that I will not hold individual confidences of either party that will jeopardize my allegiance to or neutrality with both parties in the couple.

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CONFIDENTIALITY:
I will keep what you tell me confidential with the following exceptions as mandated by the law:
1. You direct/allow me to tell someone else by signing a release of information.
2. I determine you are a danger to yourself or to others.
3. I am ordered by a court to disclose information.
4. You abuse a child or an elderly person
5. If you are under 18 years old and you report you are a victim of physical or sexual abuse.
*Children and adolescents have additional limits to confidentially which will be addressed in the initial assessment.  These limits pertain to but are not inclusive of alcohol and drug use, running away, truancy, sex and other safety issues.  It is my policy to attempt to communicate with both parents of minor children. A letter will be sent to the parent who is not in attendance at the initial intake. If you have joint legal custody this is mandatory.

CONTACTING YOU:
When I contact you I will attempt to be discreet when identifying myself. If there are special instructions about how to contact you and if a message cannot be left you must let us know.  I contact clients by email occasionally, for scheduling appointments, sending intake forms, statements, and referral resources. Please provide your email address on the intake form in order for me to email you. 

ETHICAL GUIDELINES AND STANDARDS:
I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards for licensed clinical social workers. If at any time you are dissatisfied with my services, please let me know. I am open to discussing any concerns you may have regarding our work together.  

PAYMENT or CO-PAYMENT (CHECK or CASH ) IS DUE AT THE BEGINNING OF EACH SESSION.
**INITIAL SESSION (private pay)              $ 95 (50 min session) also includes administrative work

**THERAPY SESSION (private pay)           $ 95 (50 min session) for Individual and Family Therapy

**PHONE CALLS: (longer than 10 mins)   $1.00 a minute after first 10 mins (first 10 mins at no charge) 	                                                                                  

**TIME RE: (NON-SESSION TIME):         $ 50 an hour (Ex.: consultations with others at your  	                       	                                                                   request)

**PAPERWORK TIME:                                $ 50 an hour (Ex.: writing reports related to you at your                  
						       request)

**OTHER CHARGES:                                   $25 for a check returned for “insufficient funds”
 						    $25 for no show
						    $10 billing fee
						    $35 fee if your account is sent to collections
**Please be aware that I charge for and expect payment for phone time (time after the first 10 minutes) and for non-session time related to you. Payment is due at your next session following the rendering of 
these services. I will provide a statement for you upon request. If I raise my therapy fee, you will be given at least 60-days notice.
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APPOINTMENTS:
I will make every effort to begin and end sessions on time. Your next appointment will be scheduled at the end of each session. Please be mindful of the length of your session as I generally have consecutive appointments and want to be respectful of the next person’s time. If you cannot keep your appointment time, please give me at least a FULL 24 hours notice.  If you are going to be more than 15 minutes late for your appointment, please let me know by calling 315-945-8530 and leaving a message on my office voice mail. Otherwise, if you are more than 15 minutes late, I will assume you are not coming to the appointment. Fees for, and lengths of sessions are not pro-rated if you are late. I most likely have another client waiting, since I schedule one client per hour.

INSURANCE:
It is your responsibility, as the client, to obtain any authorizations needed from an insurance company. If the insurance company denies any service it will be your responsibility to pay for these service and attempt to collect reimbursement from the insurance company. As a courtesy to you, I will submit your insurance claims. I will submit any rejected claim a second time. If after the second attempt a claim is denied, it will then be your responsibility to pay me in full and attempt to collect it yourself. I will provide you with the necessary information your insurance company will need.

CONSULTATION:
In keeping with accepted standards of practice and to ensure quality of care, I regularly consult with other mental health professionals regarding clients. Client identity is protected at all times.

RECORDS:
Your file is kept for at least 7 years from first date seen. For minors, this 7 year period begins when you turn 18 years old. Your file contains my copy of this informed consent, your client information form, and all materials that pertain to you, including notes I take. This file is confidential with the exceptions noted in the Confidentiality section. Your file is protected by two locks and will be destroyed by shredding at the end of seven years.

TERMINATION:
Your decision to enter counseling is a voluntary one and you may terminate counseling at any time you wish without penalty. Termination of the counseling relationship is also a natural occurrence when your goals for counseling have been met. The counseling relationship may also be terminated if, in my professional opinion, it is in your best interest for me to refer you to another therapist, as ethical standards dictate this course of action (See Counseling Philosophy) Termination will occur automatically if I have not seen you in a counseling session for 4 weeks from the date of our last scheduled session, unless you and I have a prior agreement to leave your case open for a specified amount of time. Should you re-enter counseling with me after your case has been closed, you may be required to complete this paperwork process again and any new changes will apply when you re-enter treatment.

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MY PERSONAL STATEMENT AND PHILOSOPHY ABOUT BEING A THERAPIST:
I believe it is crucial for me, as a therapist, to take very good care of myself physically, emotionally, psychologically, educationally, and spiritually. I do this in a number of ways. I believe it is important to balance work, personal and family time and I do my best to practice what I preach by taking care of myself in ways that reflect this belief. This means there will be times when I will not be available. On rare occasions, I may be unavailable for 2-3 weeks at a time.  I will inform you of my planned absence in advance. Should you need support during this time, I will provide you with the name and number of another therapist you can contact if you feel the need to do so.

Your signature indicates that you agree to adhere to the policies on all five pages of this “Consent to Treatment” document for Brigitta Lalone, LCSW-R.

______________________________________________________ ________ / _______ / _________
Client Signature Date

NOTICE OF PRIVACY PRACTICES FOR THIS OFFICE
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting me at (315) 945-8530.  You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

I acknowledge I have been offered the right to review the HIPPA “Notice of Privacy Policies”.
X _________________________ X _____________________________ _____/_____/_____
(PRINT) Client Name Client Signature Date