Client Information:

Name: First ___________________________________ MI. ____ Last ____________________

SS# __________________________________ DOB _______________________ Age _______

Male ___  Female ___ Married ___ Single ___ Separated ___ Divorced ___ Widowed ___

Street Address  _________________________________ City ______________ ZIP _________

Home Phone _______________ Work Phone _______________ Cell Phone ________________

Student? Y  N Full-Time__ Part-Time __ Are You Employed Y__ N__  If Yes:  F-T __ PT ___

Employer Street Address ________________________ City ________________ ZIP ________

Insurance Information

Name of Policy Holder Last, First MI _______________________________________________

Primary Insurance Company ___________________________ Ins. Co. Phone # _____________

Policy Holder SS# _______________ Policy Holder DOB _____________

Subscriber ID _____________________________________ Group # ____________________

If Client is a Minor

Mother’s Name: _____________________________________ Phone# ____________________

Street Address: ___________________ City ______________ State _____________ Zip ______

Mothers Employer _________________________________ Phone#  _____________________

Fathers Name _____________________________________ Phone# ______________________

Street Address _____________________ City _________________ State _______ Zip _______

Fathers Employer _______________________________________ Phone# _________________

Referred by: PCP: ___ Psychiatrist ___ Counselor ___ Friend ___ Internet ___ Ad ___ Other _

Assignment and release: I hereby authorize the benefits to be paid directly to the counselor. I agree that I am financially responsible for non-covered services. I authorize the counselor to release any information required to process my claims.

Signature: ______________________________________________ Date: ________________

In case of emergency, name of nearest relative or friend we should contact:

Name _________________________________ Address ________________________________

Phone# ___________________ Email address ________________________________________

 

Counseling Services of Conroe

Please provide a brief history for us to best assist you in meeting your therapeutic goals.

Education (check all that apply):

GED ___ HS Graduate ___ 2 year AA/AAS ___ 4 year BA/BS ___ Masters & up ___

Military Service:

Have you served in the military?  Y  N  Which Branch? _____________ Discharge date?______

Family History (Please circle response):

Who raised you? Biological Mother Y   N  Stepmother Y   N  Grandparent Y   N  Other Y   N

Biological Father Y   N  Stepfather Y   N  Grandfather Y   N  Other Y   N

Number of siblings? Full Blood _____  Half ______ Step ______

Counseling History:

Have you received assistance from any of the following?   Psychiatrist   Psychologist   Therapist

LCSW    Inpatient/Outpatient Hospital    Drug Abuse Treatment    Self Help Support Groups

Please explain each item circled: ___________________________________________________

Substance Abuse History:

Circle the alcohol or drugs you have used/abused or currently take without a prescription.

Alcohol  Marijuana   Cocaine (crack/powder)   Methamphetamine   Heroin   Ecstasy   Opiates

Synthetic marijuana (K2, Spice, Fake Bake)   PCP  Hallucinogens   Inhalants   Steroid   Bath Salt

Other prescription drugs-antidepressants   Non prescription drugs i.e. cough syrups, Sudafed

Does anyone in your family have an alcohol/drug problem?   Y   N  If yes who? _____________

Medical/Mental Health History:

List medical/mental health diagnosis for which you are currently being treated:

 

Current Medications prescribed:

______________________________________________________________________________

Family history of medical or mental health problems: ______________________________________________________________________________

 

Medical/Mental Health History:

Please circle symptoms/behaviors that are problematic for you.

Aggression   Alcohol Dependence   Anger   Hallucinations   Anxiety   Avoiding People   Depression   Dizziness   Drug Dependence   Eating Disorder   Phobias/Fear   Fatigue   Gambling   Sexual Addiction   Hopelessness   Impulsivity   Irritability   Judgment Errors   Loneliness   Mood Memory Impairment   Hyperactivity   Panic Attacks   Pornography   Trembling Withdrawals Disruptive Thoughts   Spending Problems   Sexual Difficulties   Sleeping Problems   Worrying    Suicidal Thoughts   Disorganized Thoughts   Social Problems   Isolating

Explain how the above items impact your daily functioning:

 

 

Stress Indicators:

Were there special or unusual circumstances that affected you in childhood? (i.e car accidents, domestic violence, trauma, natural disasters, significant loss of a loved one)     Y         N

Please explain any unusual events that have occurred in the last 12 months. ______________________________________________________________________________

______________________________________________________________________________

Counseling Goals

What would you like to accomplish with counseling?

________________________________________________________________________

________________________________________________________________________

 ________________________________________________________________________

________________________________________________________________________

Counseling is a process in which you will grow, learn about yourself and the world around you such that stressors, substance abuse and other barriers might be removed. Cognitive Behavior Therapy and Solution Focused approaches help you gain these insights.  

Thank you for selecting Counseling Services of Conroe. We wish to do our best in making this experience meaningful. Please read the pages thoroughly and ask questions for clarification as needed. The information provided will allow us to provide services that will be meaningful and appropriate for you.

Rate Policy

Per Session                                                    $120                                      45-50 minutes

Phone Time                                                   $30                                        10 minutes

Other Fees (Prorated)

Court Testimony or deposition                    $500                                      per hour (2 hour min.)

Local travel                                                  $125                                      per hour (1 hour min)

Waiting/preparation for testimony               $250                                      per hour

Records Review                                           $125                                      per hour

Consultations and other services                  $125                                     per hour

Returned check fee                                       $25                                       each item

*Sliding Scale fee available based on income

Changes and Cancellations:

At times, the unexpected occurs, like inclement weather or your child becomes ill. Your appointment is important though and your therapist is happy to accommodate you with a phone session so that you can care for your sick child or alleviate concerns about the weather. We can help you keep your scheduled appointment, provided that you are in a confidential location. Please keep in mind: most insurance plans will not pay for phone therapy. If you still must change or cancel your counseling appointment, please be aware of the following:

  • Cancellations must be made no less than 24 hours before the scheduled appointment.
  • We cannot accommodate cancellations made after hours or on holidays. If you have an appointment on Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment.
  • Cancellations without the aforementioned notice will result in a fee of $30 that will be collected at your next appointment, or if payment information is on file, it will be debited from your credit card.
  • After three no-shows/late cancellations, you will be referred out to another counselor for continuation of services.
  • Additional services related to court preparation including correspondence with attorneys or other service providers via phone, email, or letter, documentation review and or documentation preparation are also billed at $250 per hour, at a two hour minimum.

Your signature below indicates that you have read this agreement and agree to its terms in its entirety.

 

Signature ___________________________________________ Date __________________