Intake Questionnaire and Forms
Brief Intake Questionnaire, Informed Consent Forms, Privacy Notices, and Practice Policies
Moscow Counseling LLC | 828 S. Washington St., Suite C | Moscow, ID 83843
Client's First Name
Client's Last Name
Client's Date of Birth
City, State, Zip
Call and or Text Allowed for this Number?
Do Not Call
Do Not Text
Contact via Email Allowed?
Name of Emergency Contact
Relation of Emergency Contact
Emergency Contact Phone Number
Client's Gender Identity / Expression
Client's Ethnicity / Cultural Background
Client's Sexual / Affectual Orientation
Client's Preferred Pronouns
Client's Religion / Spiritual Beliefs
Briefly describe the purpose for seeking counseling.
Please check any of the following symptoms you are currently experiencing:
Disordered Eating Habits
Episodes of panic
Feeling awkward in social situations
Feeling easily annoyed
Lack of interests or motivation
Sleep disruptions | Feeling excessively tired
How long have you been experiencing mental health concerns?
Have you ever been in counseling before?
Please list any medications or supplements you are currently taking.
How did you hear about Moscow Counseling?
Friend / Relative
Moscow Chamber of Commerce
Physician / Practitioner
University Counseling Center
Informed Consent for Counseling
Cheryl McGill, MS, LPC, NCC earned a M.S. in Clinical Mental Health Counseling at Walden University. Cheryl is a Licensed Professional Counselor in the state of Idaho and a National Certified Counselor with the National Board of Certified Counselors.
Idaho License #: LPC-7209, NBCC Certification #: 1095398, National Provider Identifier #: 1285125690
Morgan Bond, LMSW earned a Master’s of Science in Social Work from Columbia University. Morgan is a Licensed Master in Social Work in the state of Idaho.
Idaho License #: LMSW 40311
THE COUNSELING RELATIONSHIP
The counseling relationship is very unique. It is highly personal and private while also including necessary healthy boundaries and therapeutic expectations. Given this, it is important for us to have a clear understanding about how the counseling relationship will work. Sexual intimacy, abuse, and personal influence is never appropriate with a client and should be reported to the Idaho Division of Occupational and Professional Licenses - 11351 W. Chinden Building #6, Boise, ID 83714 OR PO Box 83720, Boise, ID 83720 (208) 334-3233.
THE THERAPEUTIC PROCESS
The outcome of treatment is largely influenced on a client's willingness to engage in this process. At times the process may result in emotional discomfort. For example, remembering unpleasant events and becoming aware of feelings attached to those events can bring about strong emotional responses such as anger, depression, anxiety, etc.
There is a potential for increased frequency and intensity of presenting symptoms during treatment. We will do our best to understand and support our clients through the counseling process. However, we cannot promise that circumstances will change or improve to one's expectations.
The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named individuals or entities. For clients under the age of eighteen, parents have a right to receive periodic progress updates. However, underage clients have the right to privacy. Should any client under the age of eighteen disclose information that pertain to the limits of confidentiality, parents will be notified immediately.
LIMITATIONS OF CONFIDENTIALITY
There are limitations of confidentiality that include:
If a client threatens or attempts to commit suicide or otherwise conduct themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If we have reasonable suspicion that a client or other named person is the perpetrator or actual victim of neglect, physical, emotional or sexual abuse of children, elderly, or other vulnerable populations.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for our clients. Information about clients may be shared in this context without using any identifying information.
Court Appearance Contractual Agreement
Clients are strongly discouraged from having their therapist subpoenaed or having them provide records for the purpose of litigation. Being responsible for the testimony fee does not mean that the therapist’s testimony will be solely in your favor. Therapists can only testify to the facts of the case and their professional opinion, which may not provide the outcome clients are seeking. In addition, asking your therapist to provide confidential records or testify on your behalf can significantly damage the trust built in the counseling relationship, especially if the therapist is still working with that client in therapy.
Please note that if one of our therapists is subpoenaed to testify or provide records in a case where the client is a child, the therapeutic relationship is effectively ended and it is very likely we will not continue to provide services to that child/family.
If a therapist with Moscow Counseling LLC is to receive a subpoena, then the attorney or office staff will need to call the office and set up a time for the subpoena to be served during office hours. The therapist will request a minimum of 72 business hours notice of any court appearance so that schedule changes for their clients can be made within a reasonable time frame.
If a subpoena or notice to meet attorney(s) is received without a minimum of 72 business hours notice, there will be an additional $250 express charge.
When it comes to court-related actions, the following fees are in effect:
1. Preparation Time (including submission of records): $200/hour (billable in 15 minute increments)
2. Phone calls: $175/hour (billable in 15 minute increments)
3. Depositions: $275/hour
4. Time required in Giving Testimony: $250/hour
5. Compensation for Travel Time: $125/hour plus any costs for air travel, fuel, mileage ($.60/mile), and accommodations
6. Time Away from office due to Depositions or Testimony: $220/hour
7. All attorney fees and costs that are incurred by the therapist as a result of the legal action.
8. Filing document with the court: $100
9. The minimum charge for a court appearance: $2000
A retainer of $2000 is due at least 72 business hours BEFORE the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. If the therapist is subpoenaed and the case is reset with less than 72 business hours notice prior to the beginning of the day of the scheduled subpoena, trial, and/or testimony is not given, then the client will be charged $500 (in addition to the original retainer of $2000 for having to appear in court). All fees listed above are DOUBLED if the therapist has been scheduled to be out of town, out of the office, or on vacation on the date of the court appearance.
Consent for Online Counseling
TOOLS: You will need access to the technological tools and services to participate in Online Counseling such as a computer or smartphone with a webcam and high-speed internet. If you do not have access to such, we will conduct your Online Counseling session via a phone call. By providing your phone number, you are providing permission to contact you via phone should technical issues arise.
RISKS: Online Counseling has both benefits and risks. Some of these risks include: (a) Internet connections and cloud services could cease working or become too unstable to use, (b) Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out, and (c) Your counselor does NOT have the ability to directly intervene in crises or emergencies.
SAFETY: You are required to provide Moscow Counseling LLC contact numbers for mental health crises and medical emergencies. By providing the name and phone number of an emergency contact, you are also providing permission for your Counselor to communicate with these contacts about your care during emergencies. If you are in immediate crisis, you will need to call 911 or report to the nearest emergency room. If your counselor has reason to suspect that you can not or will not contact emergency services or report to an emergency room, your counselor will call 911 on your behalf.
PRIVACY: Moscow Counseling LLC employs software and hardware tools that adhere to security best practices and applicable legal standards which are HIPAA Compliant. However, you also have a role to play in maintaining your security. You will be responsible for creating an appropriate, safe, and private/confidential space for your Online Counseling sessions. You will need a space that is free of other people and this space should also be difficult for people outside the space to see or hear your interactions with your counselor during the Online Counseling session.
APPROPRIATENESS: Although it is well validated by research, Online Counseling is not a good fit for every person. Together, we will continuously assess if Online Counseling is appropriate for you. Please let your counselor know if you find Online Counseling too difficult to use, if it distracts from the services being provided, if it causes trouble focusing on your services, or if there are any other reasons why you find Online Counseling inappropriate for you. We will develop alternative means for service.
APPOINTMENTS, CANCELLATIONS, AND TARDINESS
The standard session time is 50 minutes. Requests to change the 50-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
Please remember to cancel or reschedule 24 hours in advance. The cancellation policy is necessary because a time commitment is made to you and is held exclusively for you.
**Cancellations not received at least 24 hours in advance of your scheduled session start time or being absent from your scheduled session without notice will be subject to a $20 late cancellation/no-show fee.**
*If you are late for a session, you will lose some of that session time. Tardiness or online counseling technical difficulties will NOT extend your scheduled session end time.*
COMMUNICATION BETWEEN SESSIONS
If you need to contact your therapist between sessions, we will attempt to return messages in a timely manner, but cannot guarantee immediate response and request that you do not use these methods of communication to request assistance for emergencies.
If a true emergency situation arises, please call 911 or any local emergency room.
We do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy.
Electronic communication includes, but is not limited to, telephone communication, the Internet, facsimile machines, and e-mail. If others have access to your electronic equipment, we cannot ensure the confidentiality of any form of communication through electronic means, including messages sent to you.
The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion with you and a termination process if we determine that the psychotherapy is not being effective. We will not initiate termination of the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. However, you have the right to end the counseling relationship for any reason at any time and we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
** Should you fail to attend your scheduled appointment three consecutive times without notice, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued and you will be removed from the schedule.**
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT CLIENTS:
We keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
For our use in treating you.
For our use in defending ourselves in legal proceedings instituted by you.
For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
Required by law and the use or disclosure is limited to the requirements of such law.
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
Required to help avert a serious threat to the health and safety of others.
II. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE AUTHORIZATION. Subject to certain limitations in the law, we can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on the premises.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
III. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests.
Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record. We will provide you with a summary within 30 days of receiving your written request, and we may charge a reasonable fee for doing so.
Agreement to Consent, Policies, and Practices
BY CHECKING THIS BOX AND TYPING MY NAME BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Client/Legal Guardian Electronic Signature (Type Full Legal Name)
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