WHY THESE QUESTIONS? Lighthouse Christian Counseling wants to make sure your paid session is focused on your direct needs.
These questions help the counselor maximize their time in session with you by reducing the number of closed-ended questions they have to ask you.
It will take about 15 minutes to complete this form.
Please reach out to the office at (970) 413-8998 if you have any questions or difficulties! Today's Date* MM slash DD slash YYYY
Counselor to be seen* Choose Your Counselor Chris Bassett, LMFT Kathy Estep, LPCC Maggie Kelleher, LPCC Ramona McGonagil, LPCC Micah Strouse Jen Hahn, LPC Bob Weinkauf, MA Emily Baker Jacqueline Elliff, LPC
Consent to Counseling Lighthouse's Counselors are all licensed, or pursuing licensure, under the following guidelines, as outlined by federal and state regulations. I consent to counseling with the above named counselor. I understand that I can ask for more information about my counselor by contacting the office at (970)413-8998.
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations boards and can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family therapist, and a Licensed Professional Counselor must hold a Master’s degree in his or her profession and have two years of post-Master’s supervision. (A Licensed Psychologist must hold a Doctorate degree in psychology and have one year of post-doctoral supervision.) A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure.
Your Name* First Last
Relationship to Client* Self Husband Wife Partner Mother Father Stepmother Stepfather Guardian Child Sibling Family Member Other
Your Date of Birth* MM slash DD slash YYYY
Your Address* Your Phone Number*
Preferred Method of Communication* Your Email*
Your Sex*
Your Marital Status* Your Employment* Client Name* First Last
Client Phone (If different than above)
Client Preferred Method of Communication* Client's Date of Birth* MM slash DD slash YYYY
Client's Sex*
Client's Address* Are you here for Couples or Family Counseling?* Other Client's Name* First Last
Other Client's Phone Number*
Other Client's Email*
Please list the names, phone numbers, and emails for each additional person who is a client* Minors: At the age of 12, a minor is considered, by law, able to consent for counseling with or without a parent's signature. If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.* Consent to Christian Counseling* Because you are receiving counseling from Lighthouse Christian Counseling, you are entitled to know that each of the therapists practice counseling from a Christian perspective. Please feel free to ask questions or discuss this information at any time.
HIPAA / Privacy Practices* I hereby acknowledge that I have been given an opportunity to read a copy of Lighthouse Christian Counseling’s Notice of Privacy Rights. I understand that if I have any questions regarding the notice or my privacy rights, or would like a copy of these practices, I can contact the office at (970) 413-8998 or info@lighthousecounselingnoco.com.
Mandatory Disclosure Statement The Colorado Department of Regulatory Agencies has the general responsibility of regulating the practice of licensed and unlicensed counselors and marriage and family therapists. The agency with this responsibility is the State Grievance Board, 1560 Broadway, Suite 1350, Denver, CO, 80202, 303-894-7766. The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family Therapist, and a Licensed Professional Counselor must hold a master's degree in their profession and have two years of post-master's supervision. A Licensed Psychologist must hold a doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a master's degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate, and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Counselor I (CACI) must be a high school graduate, and complete required training hours and 1,000 hours of supervised experience. A CAC II must complete additional required training hours and 2,000 hours of supervised experience. A CAC III must have a bachelor's degree in behavioral health, and complete additional required training hours and 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master's degree and meet the CAC III requirements. A Registered Psychotherapist is registered/listed with the State Board of Registered Psychotherapists, but is not licensed or certified by the state, and no degree, testing, training or experience is required to obtain registration from the state. You are entitled to receive information from your therapist about the methods of therapy, the techniques used, fee structure and the duration of your therapy (if known). You may ask questions about your therapy at any time. You may discontinue therapy services at any time and for any reason. You are entitled to receive a second opinion from another therapist. If necessary, referrals to other counselors or marital and family therapists will be made available. In a professional therapeutic relationship sexual contact of any kind between a therapist and a client is never appropriate. If sexual intimacy between a client and therapist occurs, it should be reported to the State Grievance Board.
CONFIDENTIALITY:* Both professional ethics and the Colorado State Mental Health Code-CRS 112.43.214 (1) (d) require that your privacy be carefully protected. Generally speaking, information provided by and to a client in therapy is legally confidential and will not be released to anyone without your written permission. Confidentiality can be broken by your therapist in certain circumstances as required by Colorado law (listed in section 12-43-218 of the Colorado Revised Statutes and the Notice of Privacy Rights you were provided) These circumstances are summarized below: (1) if you sign a release of information form that allows me to disclose information to individuals or institutions specified by you; (2) if you are using insurance benefits, I may disclose relevant information regarding diagnosis and treatment if requested by your insurance company; (3) if you are in danger of causing immediate harm to yourself or another person, I am required by law to report this to appropriate authorities; (4) if I am ordered by a court of law to disclose information about you (e.g., if I am served with a legitimate subpoena), I am required in some cases to respond to that order; (5) if you reveal information concerning neglect, physical or sexual abuse of a child or an elder, I am required by law to report this knowledge to the appropriate authorities; (6) if you are in therapy by order of a court of law; (7) if you are involved in a criminal or delinquency proceeding; (8) if I need to provide another therapist with pertinent information when that therapist is on-call for my practice in my absence, or if, I consult with another colleague about your treatment. Supervision and case consultation of cases will occur with staff members of Lighthouse Christian Counseling. Any objections to this supervision or known affiliations with these parties should be shared with your therapist immediately. Couples attending therapy together are informed that information shared with the therapist by one individual may be disclosed to the other party at the therapist's discretion. Other than these exceptions noted above, information shared in therapy is privileged communication and cannot be disclosed in any court of competent jurisdiction in the state of Colorado without your consent. Information shared in couple's therapy when both parties are present cannot be disclosed to other parties without the written consent of both parties attending the couples' sessions. Our online forms and communications through TherapyNotes are secure. Any information you choose to send, or request your counselor send through any other method is not secure. Please consider using these other means of sharing information carefully, as Lighthouse is not liable for how you choose to share information.
Tele-therapy Consent* TELE-THERAPY / E-THERAPY I hereby consent to engaging in tele-therapy and/or electronic therapy with Lighthouse Christian Counseling, as part of my mental health treatment. I understand that "tele-therapy" and "electronic therapy includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications such as the telephone, cellular phones, the internet, and various programs such as Zoom and FaceTime. I understand that if I am experiencing an emergency, seriously considering harming myself/suicide, or considering harming someone else that I should immediately go to the hospital or call 911 for help. I understand that I have the following rights with respect to tele-therapy and/or electronic therapy:
(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
Release of Information* For any information regarding a client to be shared outside of the above parameters, a the client must sign a Release of Information form if client is 12 or older. If the client is younger than 12, it must be signed by the responsible party. Lighthouse does not release case notes, even to the client. When requested, the counselor will write a summary. This is billed by the minute at the client's session rate.
Illness/COVID Policies* Any person my be exposed to communicable illnesses, such as a cold, the flu, or COVID (also known as “Coronavirus)" at any time or in any place. Lighthouse is following local, state, and federal recommendations and regulations to limit the transmission of all diseases in our office. Despite our efforts to use personal barriers, and maintain social distance, choosing to participate in in-person sessions means there is a possibility that you could be exposed to an illness in our office, just as you might at any public place. Lighthouse Christian Counseling has taken measures to maintain social distancing in our office; however, it is not always possible to maintain this social distancing between the client, counselor, staff, and other clients. If you do not feel comfortable with this risk, Lighthouse offers Teletherapy through our HIPAA compliant system, Simple Practice. If you have been exposed to a communicable disease, you may spread the disease to the counselor, staff, or other clients. If you are not feeling well, exhibiting any signs related to COVID, or have been exposed to someone with COVID, please contact your counselor to switch to tele-therapy or reschedule your appointment.
Masks* I understand and accept the risk associated with counseling in-person, agree to follow the mask policy, and switch to teletherapy if I have been exposed to someone with any communicable illness. By checking this, you are eSigning this form.
Lighthouse Christian Counseling strives to strike a balance with respecting your wishes and abiding by local, state, and federal regulations.
Termination of Services* I understand Lighthouse Christian Counseling's Termination of Services practices.
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your counselor may terminate treatment after appropriate discussion with you and a termination process if they determine that the psychotherapy is not being effectively used or if you are in default on payment. Your counselor will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating.
Financial Policies- Late fees, insufficient funds, work outside of sessions, etcetera.* I agree to abide by Lighthouse Christian Counseling's Financial Policies
The fee for therapy is based on a sliding fee scale based on information provided below and is the fee for a 50-60 minute session. The fee will be discussed with you prior to your first appointment. You have the right to ask for a Good Faith Estimate at any point in time before or during your services. You can request your Estimate by calling our office at (970) 413-8998.
Aknowledgement of Good Faith Estimate for Health Care Services* I understand I will be given a Good Faith Estimate for all services not covered by insurance.
Per the No Surprises Act, because Lighthouse does not accept any insurance, you are entitled to receive a good faith estimate for your services here at Lighthouse. You can contact our office to request your estimate at any point in time before or during your treatment at Lighthouse. (970) 413-8998 or info@lighthousecounselingnoco.com
Are you/the client on Medicaid? Pease provide the name and contact information for your Community Sponsor (the person paying for your sessions).*
Do you need a superbill to submit to insurance? (Please note that Lighthouse cannot provide a superbill for any sessions utilizing the sliding fee scale)* To determine your session fee, please indicate your annual gross (pre-tax) income for your household. Are you splitting the cost of services with anyone?* Please provide the name and contact information for any other party responsible for billing.*
Would you like to receive our email newsletter we send 1-2 times a month? Why are you (the client) seeking help now?*
What is happening or is different? What stressors do you have? What do you hope will be different by seeking help?
Please give more details about the issue you named above:*
When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?
Have you (the client) ever experienced similar or other mental health symptoms before?*
If so, what was your experience like? When did it happen? Did you get help?
Has anyone in your (the client) family ever experienced mental health or substance use issues?*
If so, who was it? Did they seek help or get a diagnosis? What was it like for them? What was it like for you?
Do you (the client) have any current or prior medical issues?*
If so, what was/is it? Have you seen a doctor or other healthcare professional for it? What recommendations or treatment did you have? Is there any family history of disease?
Are you (the client) currently prescribed any medications?*
If so, please list the name, dosage, how often you take it, and the prescriber for each medication.
Do you (the client) now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed?*
If so, which? When did you start, how often did/do you use, and how long did this occur? Please list each substance separately.
Who is in your (the client) family? What is your (the client) relationship with them like?*
Please list all individuals you consider to be a part of your family. For those who are not part of your family of origin (such as significant others), please include the duration of your relationship.
What social activities and relationships do you (the client) engage in?*
What important social relationships do you have? Do you belong to any social clubs or organizations? How do you like to spend your leisure time?
What spiritual practices and cultural influences are important to you (the client)?*
Do you belong to a religious, faith, or spiritual community? What other cultural groups do you identify with? How do you celebrate culture and spirituality in your life?
What was life like as you (the client) were growing up, both at home and in school?*
Did you meet developmental milestones on time or experience any delays? What were your friends like when you were younger? What was school like for you?
What significant educational and work/volunteer experiences have you (the client) had?*
What is the highest level of education you have completed? Are you currently employed? If so, where and for how long? What other work and educational experiences have you had (such as a stay-at-home parent or semester abroad)? Are you satisfied with your current employment and education?
Do you (the client) have any current or prior legal issues?*
Were you ever arrested or charged with a crime or misdemeanor? Do you have any involvement with the civil courts, such as a lawsuit or family law matter? If so, please describe them.
What strengths and abilities are you (the client) bringing to sessions? What needs or preferences do you (the client) have that will help us be successful?*
What coping skills have been working for you so far? What is important to know that will help make our time more effective for you?
What else is important to know about you (the client)?*
When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?
Do you have any other documents you want us to see?
Please upload any documents you would like us to see. Custody Arrangements, Guardianship, Medical History, etcetera.
Name
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