New Client Form

Hidden Lakes Counseling • 1744 Keller Parkway • Keller, TX 76248 • 817.854.3201

New Client Form (click here for printer friendly PDF version)

Personal Information Counselor:
First Name:  Middle Initial: Last Name: Today’s Date:
Mailing/Street Address:   City  State Zip
Preferred Phone:   Home   Work   Mobile May we leave a message?   Yes   No
Other Phone:   Home   Work   Mobile May we leave a message?   Yes   No
Email Address:                                                       May we email you?   Yes    No
 Employer Name:
Birth Date:   Male Female   Single  Married   Divorced  Other____________ Preferred Religious Denomination :
List current or previous health problems:   List of current medications: 
 Spouse  Parent Information  (if under 18)
First Name:  Middle Initial: Last Name:  Marriage Date:
Mailing/Street Address:   City  State Zip
Preferred Phone:   Home   Work   Mobile May we leave a message?   Yes   No
Email Address:  Employer Name:    
Birth Date:   Male Female   Single  Married   Divorced  Other____________ Preferred Religious Denomination : 
List present or previous health problems:   List of current medications: 
Children’s Information:  List all children
Name Birth Date Lives with you? Name: Birth Date: Lives with you?
           
           
           
           
Other Information:  Please complete this section, and use the back of this form if additional space is needed
What do you hope to change or accomplish by seeking help at this time?
List any agencies or other professionals who have provided you with counseling services in the past? 
Referred by:
Signature:  Signature (spouse):

Description of Services

Welcome to Hidden Lakes Counseling!  Counseling can help individuals and families experiencing social or emotional challenges to find solutions.  We believe each client is capable of making personal changes and enhancing their self-reliance in order to find happiness and fulfillment in life.  The following information is important for your consideration.  Your goals are more likely to be met when you understand the nature and limitations of counseling.

 

Benefits, Risks and Outcomes

Generally, counseling is most useful in helping individuals to help themselves or improve their relationships by changing feelings, thoughts, and/or behaviors.  Most people experience improvement or resolution to the concerns that brought them to counseling, but there are some risks.  For example, counseling could open up new levels of awareness that may cause discomfort.  Although we cannot guarantee the outcome of therapy, your commitment to this process will greatly influence the nature and amount of change you make.

Length of Therapy

How long a client participates in therapy can vary considerably based on the issues presented, and if new issues develop or are identified while the client is in counseling.  Certain conditions may progress quickly, while others may require considerably more time.  We believe that you should seek treatment as soon as possible, for the best outcome.  At the end of treatment, we will discuss terminating therapy or if a referral is needed to a new provider.

Confidentiality

You have received the Hidden Lakes Counseling Notice of Privacy Practices which describes your rights and our obligations regarding the use and disclosure of confidential information.  We understand that the information you share in counseling can be very personal. All clients will be presented with an Authorization for Release of Confidential Information. We will only disclose your confidential information to those whom you identify on that form, unless such release is otherwise authorized or required by law. For example, the law may require us to disclose confidential information if there is reason to believe that a child has been abused or neglected, or that you may be in danger of harming yourself or others.  See the complete Notice of Privacy Practices for more information.

Electronic Communication

As we cannot ensure the confidentiality of electronic communication, we prefer to communicate via email or text messaging for scheduling or cancellations only. Please do not use these methods of communication to discuss therapeutic content or request emergency assistance.  Due to the importance of your confidentiality and to minimize dual relationships, we do not accept friend or contact requests on social media sites.

Emergency Situations

If you find yourself in the midst of an emergency, please immediately call 9-1-1 or go to the nearest emergency room.  If you have an urgent situation, call our office, and we will see you as soon as possible. If you leave a message on our voicemail, your call may not be returned until the next business day.

Payment for Services

For doctoral (Ph.D.) level clinicians, the fee for a 50-minute session is $230.  For Masters level clinicians, the fee for an initial 50-minute assessment is $150.00, and an additional 50-minute counseling session is $130.00. The fee for a 50-minute counseling session with an LPC-Associate is $90.00. Additional time will be charged in one-half hour increments.  We take payments at the beginning of each session, in the form of cash, checks, as well as Visa, MasterCard, and Discover. As a practice, we do not participate in any health insurance plans.   However, we can provide you with a receipt to file on your own with your insurance plan.  

Cancellation of Appointment

If you need to change or cancel an appointment, as a courtesy to your counselor and the office, please notify us at least 24 hours in advance. This will allow us time to offer that appointment to someone else in need. You will be personally charged the current session fee for late cancellations or if you fail to show up for an appointment, except in emergency situations.

 Same-Sex Attraction (SSA)

We assist individuals and families as they respond to same-sex attraction. Our therapists do not provide what is commonly referred to as “reparative therapy” or “sexual orientation change efforts.”  However, for clients who self-determine to seek assistance for individual and family issues associated with same-sex attraction, we help them strengthen and develop healthy patterns of living.  Our services are consistent with applicable legal and ethical standards, which allow self-determined clients to receive assistance with personal or religious goals.

Complaints/Grievances

In the event you are concerned about any aspect of the services you are receiving, please talk to your counselor about it. You may also discuss the matter with one of our counseling supervisors,  Lisa Elieson, LPC-S or Mary King, LPC-S, by calling 817-854-3201. You have the right to file a formal written grievance with the office. It should include details of your concerns and be signed and dated with appropriate contact information to help us resolve your concerns. There will be no retaliation for filing a grievance.

Other Areas of Discussion

We encourage you to ask your counselor about the services you will receive.  Following are questions that you may want to consider asking:

  • What is the background of your counselor?
  • What are your counselor’s areas of specialization?
  • How will you be involved in the treatment plan and what methods will be used?
  • Are there other forms of help such as support groups, marriage counseling, family therapy, or other resources that may be beneficial?
  • If a referral to an outside resource is recommended, how will that be handled?

Please arrange for children to remain at home unless specifically asked to bring them as part of family therapy.  Children may not be left unattended in the waiting area.

I have read the above information, and understand that I am encouraged to ask questions and give input regarding the counseling process at any time.  If there is anything in this form that I do not understand, it is my responsibility to seek clarification.  I also acknowledge receipt of the Hidden Lakes Counseling Notice of Privacy Practices.


 

__________________________________         _____________

Signature                                                                           Date

 

__________________________________

Print name

4/2022

 

Notice of Privacy Practices

This notice describes how health information about you as a patient of this practice may be used and disclosed, and how you can get access to your individual health information.  Please review it carefully.

 

Why We Are Providing You with This Notice

This Notice will tell you about the ways in which we may use and disclose health information about you and will describe your rights and our obligations regarding the use and disclosure of that information.

Your Personal Health Information

This Notice applies to the information and records we have about your health, health status, and the health care services you receive from Hidden Lakes Counseling. This information and these records relate primarily to counseling services you have received from us.

 

Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

•           How we may use and disclose your PHI,

•           Your privacy rights in your PHI,

•           Our obligations concerning the use and disclosure of your PHI.

 

How We May Use and Disclose Personal Health Information about You

For Treatment

We may use or disclose personal health information (PHI) about you to facilitate counseling and other health treatment. For example, your counselor might disclose information about you to another Hidden Lakes Counseling therapist, so that the counselor can determine the most appropriate care for you.  Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

 

For Payment

We may use and disclose personal health information in order to collect payment for services, so that we can be paid by you, or another party if they are paying any portion of the fee for the services we provide to you.  We also may use and disclose your PHI to obtain payment from third parties that may be responsible for costs, such as family members. Also, we may use your PHI to bill you directly for services and items. You have the right to request that your health information from treatment not be shared when you pay out-of-pocket.

 

For Agency Operations

We may use and disclose health information about you in order to operate our business and make sure that you and our other clients receive quality care. For example, we may use your health information to evaluate the performance of our staff or to contact you to remind you appointments.  Please notify us in writing if you do not want us to contact you to remind you of your appointments. Our practice may use and disclose your PHI to inform you of potential treatment options or of health-related services that may be of interest to you.

Disclosures required by law

The following categories describe unique scenarios in which we may use or disclose your identifiable health information without your consent. These reasons include:

•           Disclosing your health information when we believe that disclosure is necessary to prevent a serious threat to your health and safety or the health and safety of another person.

•           Disclosing your health information as required by federal, state, or local law.

•           Disclosing your health information as required by law to prevent injury or suspected abuse or neglect.

•           Disclosing your health information in response to a court order, subpoena, warrant, summons, or similar process.

Other Uses and Disclosures of Health Information

Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Specifically, we will not use or disclose your health information from psychotherapy notes without your written authorization. Although we do not participate in fundraising, HIPAA provides you with the option to opt out of any fundraising communications. If you authorize us to use or disclose health information about you, you may revoke your authorization, in writing, at any time. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization, but we cannot take back any uses or disclosures we have already made with your permission. We have a duty to inform you if your health information is used or disclosed in a way contrary to law. Please note: we are required to retain records of your care.

 

Your Rights Regarding Your Health Information

You have the following rights with regard to your health information:

 

1.       Access to Personal Health Information.  You may inspect and obtain a copy your health information, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

 

2.       Amending Information.  If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

 

3.       Accounting for Disclosures.  You may obtain an accounting of our disclosures of your health information. This is a list of all of our disclosures of your health information for purposes other than treatment, payment, and health care operations. All of our patients have the right to request an “accounting of disclosures.”  Use of your PHI as part of the routine patient care in our practice is not required to be documented.  In order to obtain an accounting of disclosures, you must submit your request in writing to our office. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before October 25, 2013. The first list you request within a 12-month period is free of charge, but charges may apply for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

4.       Limiting Disclosures. You have the right to request that we restrict or limit our use or disclosure of your health information to only treatment, payment, or health care operations. We are not required to comply with your request. You may request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. In order to request a type of confidential communication, you must make a written request specifying the method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

5.       Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must submit your request in writing. Your request must describe in a clear and concise fashion:

•           The information you wish restricted,

•           Whether you are requesting to limit our practice’s use, disclosure or both,

•           To whom you want the limits to apply.

6.       Written notice.  You have the right to receive a paper copy of this notice.

If you want to exercise any of these rights, please contact Lisa Elieson, LPC-S at the office where you are receiving services.

 

Changes to This Notice

We have the right to change this notice. If we do so, the new notice will apply to the health information we may already have about you and to the health information that we receive in the future. We are required to abide by the most current notice that is in effect. We will post a summary of the most current notice in our office. You are entitled to receive a copy of the most current notice.

 

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with Hidden Lakes Counseling, please contact one of our counseling supervisors, Lisa Elieson, LPC-S or Mary King, LPC-S at 817-854-3201. You will not be penalized for filing a complaint.

 

This Notice is effective as of January 29, 2024.