Client Information Form

Client Information and Consent Form- PLEASE READ CAREFULLY

Your Name*
First Last
Please include your preferred first name
Please briefly share why you are seeking help today?*
Who else may be in sessions with you?
Therapist Name*
Age*
Birthdate*
MM slash DD slash YYYY
Self-Identified Gender
Address*
City State / Province / Region ZIP / Postal Code
Preferred Phone*
Preferred Email*
How did you hear about us?*
- Google Search
- Yahoo Search
- Bing Search
- Yelp!
- PsychologyToday.com
- A Previous/Current HRT Client referred me
- An HRT Therapist referred me
- My Medical Doctor referred me
- My Attorney Referred me
- Radio ad
- on TV
- Book Event/Speaking Engagement
- Office Outreach
- Other
If "Other," please tell us:
Relationship Status:*
- Single, not in a relationship
- In a relationship
- Living together
- Engaged
- Married
- Estranged
- Divorced/Annulled
- Widowed
Check all that apply.
Occupation
Employer
Religious Affiliation
If none, select "None".
Race/Ethnicity*
- Black/African-American
- Asian
- Hispanic
- Latino
- American Indian
- Alaska Native
- Pacific Islander
- Hawaii Native
- White/Caucasian
- Other
Medical History: Please include: Previous/current medial diagnoses (specify if from physician or self-diagnosed) Prescribed and OTC Medications (specify if not-compliant)
Counseling History: Please include names of therapists (specify if previous or current).
About Psychotherapy at Houston Relationship Therapy: Please type your FULL NAME to indicate you have read and understand this statement: The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your behavior or circumstance will change. We can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.*
Behavioral Life Coaching Agreement: Please type your FULL NAME to indicate you have read and understand this statement: 1. Life coaching assumes the mental health of the client. Life coaching is a collaborative process that is present and future-oriented. It is action-oriented, solution-focused, and encourages change. It involves accountability and commitment to growth through increased competence, commitment, and confidence. 2. As the client, you set the agenda for these sessions and your success will largely depend upon your willingness to define goals and try new approaches. You can expect me, as your life coach, to be honest and direct, asking straightforward questions and offering challenging techniques to help you keep moving forward. 3. Life coaching is not currently a regulated industry in the state of Texas. It will be solely the responsibility of the client to determine the effectiveness of the services rendered and the competency of the coach. 4. Life coaching is not psychotherapy or counseling. Life coaching does not address or diagnose mental disorders as defined by the American Psychiatric Association. Your life coaching sessions are not a substitute for counseling, psychotherapy, mental health care, or substance abuse treatment. Psychotherapy is a healthcare service and its primary focus is to identify, diagnose, and treat nervous and mental disorders.*
Regarding Sex Therapy/Sex-Related Coaching: Please type your FULL NAME to indicate you have read and understand this statement: Due to the nature of intimate relationships, sexual issues are often discussed at Houston Relationship Therapy. Please note that our therapists are trained to provide sexual education in several formats including, but not limited to, books, videos, models, samples, verbal explanation, paper handouts, etc. Your therapist will NEVER touch you or encourage you to touch them. She will also NEVER encourage you to touch yourself or your partner in a sexual manner in her presence. Please contact our office should you have any questions or concerns regarding the practice of Sex Therapy.*
About Confidentiality: Please type your Full Name to indicate you have read and understand this statement: The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: 1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm. 2. If a client threatens grave bodily harm or death to another person. 3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years. 4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. 5. Suspected neglect of the parties named in items #3 and #4. 6. If a court of law issues a legitimate subpoena for information stated on the subpoena. 7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney. 8. If the client discloses that he/she or any other named victim has been the victim of emotional, physical or sexual misconduct by a current/previous psychotherapist, the therapist will report any incidences to the appropriate Board. We work in a group setting, meaning that other therapists at Houston Relationship Therapy may have access to your confidential data. Every staff member is held to the same strict confidentiality practices. Occasionally we may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name. If we see each other accidentally outside of the therapy office, we will not acknowledge you first nor should you feel obligated to acknowledge us. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.*
Minors and Parents: Please type your FULL NAME to indicate you have read and understand this statement: Clients under 18 years of age and their parents: be aware that the law may allow parents to examine their child's treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child's records. If they agree, during treatment, your counselor would provide them (if requested) only with general information about the progress of your treatment, and your attendance at scheduled sessions. Any other communication to your parents will require your Authorization, unless we feel that you are in danger or are a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, your counselor will discuss the matter with you, if possible, and do her/his best to handle any objections you may have. In cases of divorce, a copy of the divorce decree indicating parental rights to view records and participate in treatment will be required.*
Kids in Session: Please type your FULL NAME to indicate you have read and understand this statement: Infants are allowed in session but please be aware that they may be a distraction to either you or your therapist. Children of any age are NOT allowed to sit outside of the therapy office unaccompanied. Please be advised that your therapist will ask you to reschedule your session (your session fee will not be refunded) should you bring children to your session who are not directly in counseling.*
If You Come to a Session Impaired: Please type your FULL NAME to indicate you have read and understand this statement: We will not engage in therapy with individuals who appear to be impaired by drugs or alcohol of any sort. Please note that if you come in to session an appear to be under the influence of any drugs/medications (legal or illegal) or alcohol, I will ask you to reschedule (your session fee will not be refunded) and refuse to see you at that time.*
Fees and Payment/Cancellation Policy: Please type your FULL NAME to indicate you have read and understand this statement: Payment is due at the time services are rendered. We cannot offer change for cash payments so please use exact change. If you do not have exact change, any remainder will be credited to your next session. Our team members’ fees per hour of psychotherapy services range from $115 to $495. Please note that therapist rates may vary and are subject to change over the advancement of their career. Updated rates for specific team members can be found at www.houstonrelationshiptherapy.com. Because we operate "By Appointment Only," cancellations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session debited from your credit card. After two no-shows/late cancellations, client will pre-pay before services are rendered. Clients who have pre-paid agree to have the entire hourly fee deducted from their pre-payment in cases of no-shows and late cancellations. Other services include emergency phone calls over 15 minutes, generating reports, consulting with other agencies and professionals at your request, providing a summary/narrative/letter, and the time spent performing any other services you may request. These services will be charged as they occur and are based on the hourly rate of the therapist. If your session must be cut short, you will be permitted to make-up for that time lost if due to therapist's need. PLEASE NOTE: By scheduling a session at Houston Relationship Therapy, you have agreed to have your credit card on file to be used under the circumstances outlined here. You may discontinue therapy at any time. If you have purchased a pre-paid premarital counseling package and choose to discontinue therapy, you may receive a 50% refund of the discounted amount you paid for any unused pre-paid premarital counseling sessions. All pre-paid sessions must be used within 1 calendar year of purchase. (No exceptions please.) Any credit card disputes will result in Houston Relationship Therapy producing a copy of this signed agreement to the company notifying us of the "chargeback" in order to recover our fees. Any additional "chargeback" fees will also be assessed to you the client. Failure to pay for our services or fees incurred by fraudulent credit card disputes will result in immediate termination of services and referral to other agencies.*
Person responsible for payment: If self, please type your name. If someone else, please type their name, phone number, and email. Please note that they will have to agree to our payment policy in order to charge them for your sessions. If they do not have that on file, you will be responsible for any payments due.*
Payment Policy: Please type your FULL NAME to show that you understand that you are ultimately financially responsible for any balance. Houston Relationship Therapy does not bill to any third party payers nor will we provide any information other than receipts of payment made by you to you should you decide to seek reimbursement for our services. We will obtain payment at the time of service or in the case of a late cancellation or no-show.*
Refund and Cancellation Policy: REFUND POLICY: Type your FULL NAME here to confirm you understand that if you have purchased a pre-paid counseling package and choose to discontinue therapy, you may receive a 50% refund of the discounted amount you paid for any unused pre-paid therapy sessions. All pre-paid services have an expiration date of 1 calendar year from the date of purchase. CANCELLATION POLICY: Type your FULL NAME here to confirm that you agree to being charged the full session fee if you do not give our office greater than 24 hours' notice should you choose to reschedule or cancel your appointment. The office will charge the credit card on file. In case of a missed couples session, both parties will be charged half of the total session fee. This confirmation will be used in case of a credit card dispute.*
How did you hear about Houston Relationship Therapy?: Please be specific: If physician, please include name and if we may thank them. If on TV, please specify program. If from an HRT client, please include their name/s so they may get $10 off their hourly rate. If from an HRT Therapist, who? If in a magazine, which one? If at an event, which one?*
May a Graduate School Intern sit-on on your sessions to observe?*
- Yes
- No
We have graduate students who get credit from their universities for not only seeing their own clients, but for observing other therapists in our practice working with clients. The intern will likely not engage in the session. They will process what happens in session after with the therapist so you will only be engaging with one therapist. You are agreeing to have them sit in, but it is not guaranteed that they will.
Our Interns and Their Supervisors: Please type your Full Name to indicate you have read and understand this statement: Our Pre-Licensed Interns are under the supervision of Board-Approved Supervisors. Our Master's-Level Interns are under the supervision of University-Approved Supervisors. The names and contact information for each supervisor can be found on the profile page of each therapist. Complaint Process: An individual who wishes to file a complaint against a Licensed Professional Counselor or Licensed Marriage and Family Therapist may write to: Complaints Management and Investigative Section, P.O. Box 141369, Austin, Texas 78714-1369 or call 1-800-942-5540 to request the appropriate form or obtain more information. This number is for complaints only.*
Emergency Contact and Phone Number: We will only contact this individual with your consent or without your consent should there be a threat to your physical safety. We may also choose to call upon 911 Emergency Services and all costs incurred will be your responsibility.*
Crisis or Emergencies: Please type your FULL NAME to indicate you have read and understand this statement: If the client is in a state of crisis or emergency, Houston Relationship Therapy recommends contacting local emergency services (ex. "911"), a crisis line, or an agency local to the client. Clients may utilize the following crisis hotlines in the United States: 1-800-SUICIDE or 1-800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).**
Acknowledgment and Release of Liability: Please type your FULL NAME to indicate you have read and understand this statement: By signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold harmless Houston Relationship Therapy and my therapist/coach from all liabilities and claims which may arise as a result of my participation in therapy/coaching.**
Signature*
I HAVE READ THIS AGREEMENT IN ITS ENTIRETY AND AGREE TO ENTER IN TO THERAPY/COACHING AT HOUSTON RELATIONSHIP THERAPY.
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