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Freedom Therapy Centers, LLC

By Albert Lee,2015-03-30 07:07
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Freedom Therapy Centers, LLC Freedom Therapy Centers, LLC 1 Disclosure Statement The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the state of Colorado. Any Questions or complaints regarding the practice of mental health may be directed to the Mental Health Grievance Board, 1560 Broad..

    Freedom Therapy Centers, LLC

    Disclosure Statement

    The practice of both licensed and unlicensed persons in the field of psychotherapy is regulated by the state of Colorado. Any Questions or complaints regarding the practice of mental health may be directed to the Mental Health Grievance Board, 1560 Broadway, Suite 1370, Denver, CO 80202, 303-894-7766. You are entitled to receive information about methods of therapy, techniques used, the duration of therapy, if known, and fee structure.

X______________________________(Date)_____________________

     (Client/Guardian)

    Freedom Therapy Centers, LLC 1

    Freedom Therapy Centers, LLC

     YOUR RIGHTS AS A CLIENT

    At Freedom Therapy Centers, LLC we use Reality Based, Person Centered, and Cognitive Behavioral approaches for all therapy methods.

    You are also to be informed of the therapist’s degrees, credentials, and licenses.

    You may seek a second opinion from a therapist or terminate therapy at any time. You should know that in a professional relationship, sexual intimacy is never appropriate and should be reported to the Grievance Board.

    You should understand that information provided by you during therapy is confidential in most circumstances. In some cases we (Freedom Therapy Centers, LLC) will consult with other therapist/ supervisors and other professionals to exchange important information. The clients name will remain confidential. There are some situations where Freedom Therapy Centers, LLC is required to disclose information without your consent or authorization:

    If a client is clearly likely to seriously harm him/herself, we may be required to take action to prevent self-destruction.

    YOUR RIGHTS AS A CLIENT

    If there is a clear risk that a client plans to seriously harm another person, we may have a duty to warn the potential victim; or disclose the risk to appropriate public authorities.

    If a therapist suspects that abuse of a child or senior citizen may have taken place, the therapist is required to report the suspected abuse to the Department of Social and Health Services.

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    Freedom Therapy Centers, LLC

    If the client is a minor younger than the age 13, both parents have access to the minor client’s complete Clinical Record, including Psychotherapy Notes, unless there is a court order prohibiting one of the parents from access.

    If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the counselor-client privilege law. Freedom Therapy Centers, LLC cannot provide any information without your (or your personal or legal representative’s) written authorization. However, if a court orders or Freedom Therapy Centers, LLC to disclose information, we are required by law to provide it. If you are involved in or contemplating litigation, please be aware that you should consult with your attorney to determine whether a court would be likely to order us to disclose information. If a client files a complaint or lawsuit against Freedom Therapy Centers, LLC or any of its staff, Freedom Therapy Centers, LLC may disclose relevant information regarding that patient in order to defend itself.

    If a client files a worker’s compensation claim, the client must sign an authorization so that

    Freedom Therapy Centers, LLC may release the information, records or reports relevant to the claim.

    Freedom Therapy Centers, LLC may present disguised case material in seminars, classes, or scientific writings. In this situation, all identifying information and Protected Health Information is removed, and client confidentiality and anonymity is maintained

     Mission Statement

    To provide you, your child and/or your family with the highest quality service in order to help you achieve your goals in therapy and in life. We offer unique, individual

    and group treatments in a serene and relaxed environment, with a friendly and caring approach by all staff.

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    Freedom Therapy Centers, LLC

    Our Treatment Approach

    Based on sound scientific models of human behavior and established methods of psychotherapy. We strongly believe that it IS possible to change, to grow, to release the past, and to evolve to wholeness. Life is a journey that leads us there. All we need to do is get ourselves out of the way, and connect to the greater good, the essence of who we truly are: divine beings connected to the authentic power that dwells inside each one of us.

    We believe….

    There is a direct correlation between one’s physical health and one’s mental health.

    When your mind and heart are cluttered with worries, anxieties and depression, it affects your physical health and is manifested in a way of high blood pressure, heart disease, weight gain, and many other physical ailments.

    When your mind and heart are at peace and are uncluttered, then you are ready to live and enjoy and Full and Rich Life!!

    "A calm and undisturbed heart and mind are the life and health of the body....."

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    Freedom Therapy Centers, LLC

     Intake Form

    Personal Information Date: _______________

Last Name: _________________________ First Name:

    _________________________ M.I.: ___

    Age: _____ Date of Birth: _______________ Gender: _____ Social Security #:

Street Address:

    __________________________________________________________________ City: _________________________ State: _____ Zip code: _______________ Ok to send mail: _____ If no, please provide alternate address: __________________________________________________________________

    Home phone: _________________________ Ok to leave a message: _____

    Cell phone: ___________________________ Ok to leave a message: _____

    Work phone: __________________________ Ok to leave a message: _____

Name of emergency contact: _____________ Relationship to you: ______________

    Address:

    __________________________________________________________________

    Home Phone: _______________Cell/Work Phone__________________

    Referral Source (how you heard about counseling services):

____________________________________

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    Freedom Therapy Centers, LLC

    Intake Form

Health Information

    Please answer the following questions using: 5 . Excellent, 4 . Good, 3 . Average, 2 . Poor, 1 - Failing

    How would you currently rate your physical health: _____

    How would you currently rate your mental health: _____

    How would you currently rate your spiritual health: _____ (if does not apply to you, please use N/A)

    Please list current symptoms (reason you are here) and circle those you currently find most bothersome:

    ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

    Medical Information

    Do you now have, or have you had in the past, any of the following? Check all that apply: Asthma

    Allergies Headaches

    Brain Injury

    Epilepsy Seizures

    Digestive Disorders

    Cancer Diabetes

    Breathing Problems Immune

    System

    Problems

    Heart Disease

    High Blood Pressure

    Vision Problems Hearing

    Problems

    Arthritis

    Urinary Disorders

    Tuberculosis

    Thyroid Disorder Multiple

    Sclerosis Chronic Fatigue

    Syndrome

    Fibromyalgia Pregnancy

    (how many)

    Miscarriage

    (how many)

    Abortion

    (how many)

    Sexually Transmitted

    Disease

    Sleep Disorder

    Serious Accident Surgery

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    Freedom Therapy Centers, LLC

Other

    Are you currently under the care of a Doctor or other medical health professional: ________ Name of Primary Care Physician: _______________ Physician Phone #: _______________ Address:

    _____________________________________________________________________________ Name of Specialist Physician: ___________________Physician Phone#: _______________ Address:

    _____________________________________________________________________________

    Please list any prescription medications you are currently taking: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please list any over the counter medications, vitamins, or herbal supplements you are currently taking:

    ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you currently exercise: _____ If yes, please indicate how many times per week: _____ Please indicate substances currently used (over the past 6 months), how much at one time, how many

    times per day/week, age of first use, past use history, and length of time used. Substance Current Amount Frequency Age Past Length

    Caffeine

    Alcohol

    Tobacco

    Marijuana

    Ecstasy

    Cocaine/Crack

    Heroin

    Methamphetamines

    PCP/LSD/Mushrooms

    Pain Killers

    Steroids

    Tranquilizers

    Sleeping Pills

    Diet Pills

    Have you ever believed your substance use was a problem for you: __________________________

    Has anyone ever told you they believed your substance use was a problem: __________________________

    Have you ever had withdrawal symptoms when trying to stop using any substances: __________________________

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    Freedom Therapy Centers, LLC

    Have you ever had problems with work, relationships, health, the law, etc. due to your substance use? If yes, please describe:

    ______________________________________________________________________________

    ______________________________________________________________________________

    Have you ever participated in drug and alcohol treatment: _____ If yes, please list type, length, dates, and age at time you received these services:

    _____________________________________________________

    ______________________________________________________________________________

    ______________________________________________________________________________

    Do you currently or have you ever attended Alcoholics or Narcotics Anonymous: _____ If yes, please list length of time sober and number of meetings you attend per week:

    ______________________________________________________________________________

    ______________________________________________________________________________

Mental Health Information

    Have you ever been in counseling/therapy before: _____ If yes did you find it helpful or effective: ______________________________________________________________________________

    ______________________________________________________________________________

    Are you currently receiving mental health services: _____ If yes, please list name of practitioner and type of services you are receiving:

    _____________________________________________________________

    Have you ever been hospitalized for mental health concerns: _____ If yes, list date(s) and length of stay:

    ______________________________________________________________________________

    ______________________________________________________________________________

    Have you ever been diagnosed with a mental illness? If yes, please list illness(es) and date (s) first diagnosed:

    ______________________________________________________________________________

    ______________________________________________________________________________

    Has anyone in your family ever been diagnosed with a mental illness? If yes, please list relationship(s) and illness(es):

    ______________________________________________________________________________

    ______________________________________________________________________________

    Have you ever or are you currently engaging in self harm? Currently: _____ Past: _____ Have you ever or are you currently contemplating suicide? Currently: _____ Past: _____ Have you ever or are you currently contemplating harming another person? Currently: _____ Past: _____

    Have you ever attempted suicide: _____ If yes please list date(s), method(s), and your age at time of attempt:

    ______________________________________________________________________________

    ______________________________________________________________________________

    Has anyone in your family ever attempted suicide: _____ If yes please list relationship: _____________

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    Freedom Therapy Centers, LLC

    Has anyone in your family ever completed suicide: _____ If yes please list relationship: _____________

    Has any one else in your life ever attempted _____ or completed suicide: _____ Relationship: ____________

    Do you currently or have you ever had trouble sleeping: _____ If yes, please describe: ______________________________________________________________________________ ______________________________________________________________________________ Do you currently or have you ever had problems with eating or with food: _____ If yes, please describe:

    ______________________________________________________________________________ ______________________________________________________________________________ Briefly describe why you are coming in for counseling and the goals you hope to achieve in therapy: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Spiritual Information

    Have you ever or do you currently engage in a personal faith practice: _____ If yes please describe: ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Have you ever, or do you currently belong to a faith community (church, synagogue, temple, religious

    order, etc.: _____ If yes, please describe your current level of connection and involvement: ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ Do you want to incorporate your faith/spirituality into the counseling process: _____ If yes, please describe how you would like to do so, and if you are specifically seeking spiritual guidance or direction:

    ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________Relationship Information

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    Freedom Therapy Centers, LLC

    Are you currently in a relationship: _____ If yes, please list status: ______________ Name of Person: ___________________ Length of time you have known each other: ________ Length of time you have been together: __________ Do you currently live together: _____ Number of marriages: _____ Number of divorces: _____ If widowed, your age at death of spouse: ____

    Do you have children: _____ If yes, please list below:

    Name Age Lives with you ________________

    Name Age Lives with you________________

    If you are coming in for Couples or Family counseling, or are currently experiencing relationship difficulties you would like to address in individual counseling, please briefly describe: ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________ Other persons living in your household and your relationship to them: ______________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Do you feel safe in your relationship?___________

    Do you or your partner have a problem with hitting?

Family Information

Were you adopted: _____ If yes, your age at time of adoption: _____

    With whom did you live until the age of 18:

    ______________________________________________________________________________ ______________________________________________________________________________ Did your parents ever divorce: _____ If yes, your age at time of divorce: _____

    I divorced, did your parents ever re-marry: _____ If yes, list parent(s) and your age(s) at time of

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