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BEGINNING COUNSELING PAPERWORK
 
First Counseling
Dr. Stewart A. Jackson
205-266-8287
 
Please provide the following information and answer the questions below. Please note:
information you provide here is protected as confidential information.
 
Please fill out this form and bring it to our first session. 
 
 
 Name: ______________________________________________________________  
                          (Last)                                          (First)                           (Middle Initial)
 
Name of parent/guardian (if under 18 years): 
 
 ____________________________________________________________________  
   (Last)      (First)                           (Middle Initial)
 
                                             
Birth Date: ______ /______ /______ Age: ________ Gender: □ Male □ Female 
 
Marital Status:   
□ Never Married    □ Domestic Partnership     □ Married     □ Separated
 
□ Divorced     □ Widowed
 
Please list any children/age: _________________________________________________

 
 
 
  
 Your Address: ________________________________________________________________                                                               (Street and Number)                         
________________________________________________________________________
   (City)              (State)            (Zip) 
 
Home Phone: _____________________________ May I leave a message? □Yes   □No 
 Cell/Other Phone: __________________________ May I leave a message? □Yes □No 
 
 
E-mail: ____________________________________May I email you?          □Yes □No 
*Please note: Email correspondence is not considered to be a confidential medium of communication. 
Would you Like an e mail reminder of your next appointment?         Yes                 No
 
Referred by (if any): _______________________________________________________ 
May I thank them?   Y         N
  
 
6. Emergency Contact ____________________________Relationship_____________
                                                Phone:______________________________________________
 
 
 
CLIENT NOTIFICATION OF PRIVACY RIGHTS
The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surround the use of protected health information. Commonly referred to as the “medical records privacy Law”, HIPAA provides patient protections related to the electronic transmission of data, the keeping and use of patient records, and storage and access to health care records. HIPAA also applies to mental health client care.
 
By law, I am required to secure your signature indicating you understand this Client Notification of Privacy Rights document. If you have any questions about any of the matters discussed above, please do not hesitate to ask me for further clarification.
 
I have read and understood the Informed Consent Form, including the Client Notification of Privacy Rights section.
 
 
_________________________________________________                        __________________________
Signature of Client (or parent if Minor or Legal Charge)                                    Date


 
 

INFORMED CONSENT FORM

PLEASE KEEP THIS INFORMATION FOR YOUR RECORDS

 

APPOINTMENTS: Your scheduled office appointment is a time specifically set aside for you.  If you are unable to keep an appointment, please notify me at least 24 hours in advance of the time of the appointment.  I must charge for the hour if you do not notify me.

 

CONFIDENTIALITY:  All clients have a right to confidentiality.  This includes all verbal, written and recorded data concerning your treatment, and may not be released without your written consent.  Limitations to these rights are:

     1) I have a legal duty to warn and protect persons threatening harm to self or others

     2) I have a legal duty to report to proper authorities any knowledge of abuse to children and      vulnerable adults,

     3) I have to comply with Alabama State Laws in regard to court ordered subpoenas/court testimony,

     4) If your insurance is billed for counseling services, I may have to send reports to insurance companies for reimbursement.

     5) Social Media:  Because your confidentiality is important to me, I do not "friend" those I see in counseling.  

FEES:  The standard fee for therapy is $120.00 for a 50 minute session or consultation.  If a sliding fee scale is needed we can discuss it.  I accept cash, checks, and most major credit cards (small fee added for credit cards)

 

PAYMENT IS EXPECTED AT TIME OF SERVICE with check made payable to First Counseling.

 

ENDING COUNSELING:  Your care and counseling with me is strictly voluntary and may be ended at your discretion.  However, it is important that we discuss any decision to stop counseling.  Normally, as counseling comes to the end, a final session will be scheduled.

 

ORIENTATION AND TREATMENT METHODS:  I am a Licensed Marriage and Family Therapist and an ordained United Methodist minister.  I practice Family Systems Therapy and use the insights from religious traditions.  I openly acknowledge my religious tradition but do not impose my thinking on you or your family.  One of the goals of counseling is to help you think clearly about your own beliefs.  The treatment methods will vary, depending on individual circumstances.  Individual, couple or family sessions may be scheduled.  Following an initial "intake" visit, one or two interviews, the usual procedure is to determine a specific number of sessions and evaluate, re-contract or end counseling at that point.  Any questions you have about the procedure or process are always legitimate.  You always have the right to decline participation in or the use of certain therapeutic techniques.  I do not treat minors without parental consent.  I do keep abreast of developments in the field. 

 

Emergency services:  As a pastoral marriage and family counselor I am concerned and care about any emergencies you might have which would require immediate attention.  I am not set up to handle emergency services 24 hours per day.  In the event of such an emergency after normal working hours, call the emergency room closest to you for assistance or contact the Jefferson County Crisis Center at 205-323-7777 or the North Alabama Crisis line at 256-716-1000.