Common use of Alternative Treatment Clause in Contracts

Alternative Treatment. Alternative modes of treatment will be discussed during the assessment process, and/or during the course of treatment planning. RELEASE OF INFORMATION FOR BILLING PURPOSES: I agree that the organization may release to and receive from any insurers, other payers, or other persons, necessary for billing and related purposes. This information may include my identity, diagnosis and prognosis, treatment for mental health and/or alcohol or drug issues and all other information contained in my record to the extent that such records are needed for billing or collection of benefits. I am aware that I have the option to pay for services at the time of my sessions. TIME PERIOD OF INFORMED CONSENT/RIGHT TO WITHDRAW: Your consent for treatment will last until the goals of treatment have been satisfactorily reached, or you or your therapist elects to terminate treatment. This consent will be renewed every 12 months. You retain the right to withdraw informed consent and terminate treatment at any time. We do ask that you discuss this with your therapist. NO SHOW: Be aware that if you miss an appointment SCC has the right to charge a fee and all future appointments already scheduled will be cancelled to make time available for other client’s. If you no show or late cancel for more than two appointments Samaritan Counseling may terminate services. My signature below indicates that my therapist has explained this informed consent and I am satisfied with my understanding of the treatment process and have been offered a copy of this document. I hereby voluntarily consent to be actively involved in treatment. Client Signature Date Parent/Guardian Signature Date Therapist Signature SAMARITAN COUNSELING CENTER OF THE FOX VALLEY CLIENT INFORMATION FORM‌ This information will be treated confidentially and used only your counselor. Please try to answer each question. Name Race/Ethnicity Sex (√) M F Age Birth Date / / Marriage/Partner (√) Single Partner Married Divorced Widowed If partner/married, please rate your relationship/marriage as . . . Very Happy Happy Unsure or Unhappy Date of partner/marriage Ages when partner/married: Client _ Partner/Spouse How long did you know your partner/spouse before relationship/marriage? Are you currently separated In the process of divorce ? Partner/Spouse name Address Phone (H) _ Phone (W) Birthdate / / Partner’s/Spouse’s occupation and employer Is partner/spouse willing to come for counseling? Yes No Uncertain If divorced, when? If widowed, when? Reason for divorce Concerns Previous partners/marriages: Dates Reason(s) for relationship/marriage ending Dates Reason(s) for relationship/marriage ending Children Check column (*) if child is by previous relationship/marriage. If more than four children, use the back of this form * Name Age Sex (F or M) Living (Yes or No) Partner/Married at the time of birth (Yes or No) Parents Were you raised by your biological parents? Yes No If not, by whom? Are your parents living? Father Mother Age you lost your parent If living, ages of Father Mother Were your parents divorced? Yes No Living together? Yes No Your age? Rate your parent’s marriage: Unhappy Average Happy Very Happy Rate your childhood: Unhappy Happy Very Happy Rate your adult life: Unhappy Happy Very Happy As a child did you feel closer to your Father Mother Another parent figure Who? Ethnic heritage: Father Mother Religious preference: Father Mother Education: (years) Father Mother Occupation: Father Mother Brothers and Sisters List in birth order, including yourself (so we know where you fit). Use reverse side for more. First Name Age Sex (M/F) Living (Y/N) Partner/Married Status Children Describe your current relationship with your parents and/or siblings: Health Rate your physical health: (√) Very Good Good Average Declining Poor Height Weight Recent weight changes? (√) Loss Gain Over how long of time Sleep: (√) No Trouble Have trouble Please explain Date of last physical exam List significant medical conditions Are you presently taking medication? If so,what? Have you ever had a “nervous breakdown” or been severely emotionally upset? Yes No Have you ever been physically abused? Yes No Have you ever been sexually abused? Yes No Have you had previous counseling? Yes No Facility and therapist When Addictions Has alcohol, drugs, or gambling ever been a problem? (√) You Spouse Parents Siblings Other family In a few words, describe the problem(s) Has your social life, work life, or relationships changed due to drugs, alcohol, or gambling? (Explain) Have you or anyone in your family ever had an eating disorder? If so, please specify Educational, Vocational, and Legal History Highest Grade completed: Highest College completed: Military History: Branch and Years of Service Wartime duty? Occupation: Employer: Other Training (type and years) Have you changed jobs recently? Reasons for the change Briefly describe involvements, at any time, with the legal system, including dates, reasons, and results) Preferred Spirituality or Religious Fellowship (i.e. church, mosque, temple, or other spiritual community) Do you participate in a faith community? If so: Worship community Location Attendance per month (circle) 0 1 2 3 4 5+ Childhood religious affiliation What would you like your counselor to know regarding your spiritual/religious experiences or needs? Life Experiences List three significant events in your life and how they were significant.

Alternative Treatment. Alternative modes of treatment will be discussed during the assessment process, and/or during the course of treatment planning. RELEASE OF INFORMATION FOR BILLING PURPOSES: I agree that the organization may release to and receive from any insurers, other payers, or other persons, necessary for billing and related purposes. This information may include my identity, diagnosis and prognosis, treatment for mental health and/or alcohol or drug issues and all other information contained in my record to the extent that such records are needed for billing or collection of benefits. I am aware that I have the option to pay for services at the time of my sessions. TIME PERIOD OF INFORMED CONSENT/RIGHT TO WITHDRAW: Your consent for treatment will last until the goals of treatment have been satisfactorily reached, or you or your therapist elects to terminate treatment. This consent will be renewed every 12 months. You retain the right to withdraw informed consent and terminate treatment at any time. We do ask that you discuss this with your therapist. NO SHOW: Be aware that if you miss an appointment SCC has the right to charge a fee and all future appointments already scheduled will be cancelled to make time available for other client’s. If you no show or late cancel for more than two appointments Samaritan Counseling may terminate services. My signature below indicates that my therapist has explained this informed consent and I am satisfied with my understanding of the treatment process and have been offered a copy of this document. I hereby voluntarily consent to be actively involved in treatment. Client Signature Date Parent/Guardian Signature Date Therapist Signature Date Parent/Guardian Signature Date SAMARITAN COUNSELING CENTER OF THE FOX VALLEY CLIENT INFORMATION FORM‌ FORM Parents of Children and Adolescents Parents: Please complete this form. This information will be treated confidentially and used only will be helpful to your child’s counselor. Please try to answer each question. Child’s Name Race/Ethnicity Sex (√) M F Age Birth Date / / Marriage/Partner Mother’s Name Father’s Name Legal Guardian(s) Age Birth Date / / Nationality Age Birth Date / / Nationality Age Birth Date / / Address Telephone (√H) (W) Step Parent’s name and address Step Parent’s name and address Parents: Single Partner Married Divorced Widowed If partner/married, please rate your relationship/marriage as . . . Very Happy Happy Unsure or Unhappy Date of partner/marriage Ages when partner/married: Client _ Partner/Spouse How long did you know your partner/spouse before relationship/marriage? Wife Husband Are you currently separated In or in the process of divorce ? PartnerIs spouse/Spouse name Address Phone (H) _ Phone (W) Birthdate / / Partner’s/Spouse’s occupation and employer Is partner/spouse family willing to come for counseling? Yes No Uncertain If divorced, when? If widowed, when? Reason for divorce Concerns _ Previous partners/marriages: Dates Reason(s) for relationship/marriage ending _ Dates Reason(s) for relationship/marriage ending _ Education: (years) Father Mother Employment: Father Mother Have you changed jobs recently? Reasons for the change Religious preference: Father Mother Other adults significant in my child’s life Other Children Check column (*Check( ) if child is by previous relationship/marriagemarriage or stepchild. If more than four children, use the back of this form *  Name Age Sex (F or M) Living (Yes or No) Partner/Education (Years) Married at the time of birth (Yes or No) Parents Were you raised by your biological parents? Yes No If not, by whom? Are your parents living? Father Mother Age you lost your parent If living, ages of Father Mother Were your parents divorced? Yes No Living together? Yes No Your age? Rate your parent’s marriage: Unhappy Average Happy Very Happy Rate your childhood: Unhappy Happy Very Happy Rate your adult life: Unhappy Happy Very Happy As a child did you feel closer to your Father Mother Another parent figure Who? Ethnic heritage: Father Mother Religious preference: Father Mother Education: (years) Father Mother Occupation: Father Mother Brothers and Sisters List in birth order, including yourself (so we know where you fit). Use reverse side for more. First Name Age Sex (M/F) Living (Y/N) Partner/Married Status Children Describe your current relationship with your parents and/or siblings: Health Rate your child’s physical health: (√) Very Good Good Average Declining Poor Height Weight Recent weight changes? (√) Loss Gain Over how long of time Sleep: (√) No Trouble Have trouble Please explain Date of last physical exam List significant medical conditions Are you Is your child presently taking medication? If so,, what? Have you Has your child ever had a “nervous breakdown” or been severely emotionally upset? Yes No Have you Has your child ever been physically abused? Yes No Have you ever been sexually Sexually abused? Yes No Have you Has your child had previous counseling? Yes No Facility and therapist When Addictions Has alcohol, drugs, or gambling ever been a problem? (√) You Spouse Parents Siblings Other family In a few words, describe the problem(s) Has your social life, work life, or relationships changed due to drugs, alcohol, or gambling? (Explain) Have you or anyone in your family ever had an eating disorder? If so, please specify Educational, Vocational, and Legal History Highest Grade completed: Highest College completed: Military History: Branch and Years of Service Wartime duty? Occupation: Employer: Other Training (type and years) Have you changed jobs recently? Reasons for the change Briefly describe involvements, at any time, with the legal system, including dates, reasons, and results) Preferred Spirituality or Religious Fellowship (i.e. church, mosque, temple, or other spiritual community) Do you participate in a faith community? If so: Worship community Location Attendance per month (circle) 0 1 2 3 4 5+ Childhood religious affiliation What would you like your counselor to know regarding your spiritual/religious experiences or needs? Life Experiences List three significant events in your life and how they were significant.Issues addressed

Alternative Treatment. Alternative modes of treatment will be discussed during the assessment process, and/or during the course of treatment planning. RELEASE OF INFORMATION FOR BILLING PURPOSES: I agree that the organization may release to and receive from any insurers, other payers, or other persons, necessary for billing and related purposes. This information may include my identity, diagnosis and prognosis, treatment for mental health and/or alcohol or drug issues and all other information contained in my record to the extent that such records are needed for billing or collection of benefits. I am aware that I have the option to pay for services at the time of my sessions. TIME PERIOD OF INFORMED CONSENT/RIGHT TO WITHDRAW: Your consent for treatment will last until the goals of treatment have been satisfactorily reached, or you or your therapist elects to terminate treatment. This consent will be renewed every 12 months. You retain the right to withdraw informed consent and terminate treatment at any time. We do ask that you discuss this with your therapist. NO SHOW: Be aware that if you miss an appointment SCC has the right to charge a fee and all future appointments already scheduled will be cancelled to make time available for other client’s. If you no show or late cancel for more than two appointments Samaritan Counseling may terminate services. My signature below indicates that my therapist has explained this informed consent and I am satisfied with my understanding of the treatment process and have been offered a copy of this document. I hereby voluntarily consent to be actively involved in treatment. Client Signature Date Parent/Guardian Signature Date Therapist Signature SAMARITAN COUNSELING CENTER OF THE FOX VALLEY CLIENT INFORMATION FORM‌ FORM Parents of Children and Adolescents Parents: Please complete this form. This information will be treated confidentially and used only will be helpful to your child’s counselor. Please try to answer each question. Name Race/Ethnicity Sex (√) M F Age Birth Date / / Marriage/Partner (√) Single Partner Married Divorced Widowed If partner/married, please rate your relationship/marriage as . . . Very Happy Happy Unsure or Unhappy Date of partner/marriage Ages when partner/married: Client _ Partner/Spouse How long did you know your partner/spouse before relationship/marriage? Are you currently separated In the process of divorce ? Partner/Spouse name Address Phone (H) _ Phone (W) Birthdate / / Partner’s/Spouse’s occupation and employer Is partner/spouse willing to come for counseling? Yes No Uncertain If divorced, when? If widowed, when? Reason for divorce Concerns Previous partners/marriages: Dates Reason(s) for relationship/marriage ending Dates Reason(s) for relationship/marriage ending Children Check column (*) if child is by previous relationship/marriage. If more than four children, use the back of this form * Name Age Sex (F or M) Living (Yes or No) Partner/Married at the time of birth (Yes or No) Parents Were you raised by your biological parents? Yes No If not, by whom? Are your parents living? Father Mother Age you lost your parent If living, ages of Father Mother Were your parents divorced? Yes No Living together? Yes No Your age? Rate your parent’s marriage: Unhappy Average Happy Very Happy Rate your childhood: Unhappy Happy Very Happy Rate your adult life: Unhappy Happy Very Happy As a child did you feel closer to your Father Mother Another parent figure Who? Ethnic heritage: Father Mother Religious preference: Father Mother Education: (years) Father Mother Occupation: Father Mother Brothers and Sisters List in birth order, including yourself (so we know where you fit). Use reverse side for more. First Name Age Sex (M/F) Living (Y/N) Partner/Married Status Children Describe your current relationship with your parents and/or siblings: Health Rate your physical health: (√) Very Good Good Average Declining Poor Height Weight Recent weight changes? (√) Loss Gain Over how long of time Sleep: (√) No Trouble Have trouble Please explain Date of last physical exam List significant medical conditions Are you presently taking medication? If so,what? Have you ever had a “nervous breakdown” or been severely emotionally upset? Yes No Have you ever been physically abused? Yes No Have you ever been sexually abused? Yes No Have you had previous counseling? Yes No Facility and therapist When Addictions Has alcohol, drugs, or gambling ever been a problem? (√) You Spouse Parents Siblings Other family In a few words, describe the problem(s) Has your social life, work life, or relationships changed due to drugs, alcohol, or gambling? (Explain) Have you or anyone in your family ever had an eating disorder? If so, please specify Educational, Vocational, and Legal History Highest Grade completed: Highest College completed: Military History: Branch and Years of Service Wartime duty? Occupation: Employer: Other Training (type and years) Have you changed jobs recently? Reasons for the change Briefly describe involvements, at any time, with the legal system, including dates, reasons, and results) Preferred Spirituality or Religious Fellowship (i.e. church, mosque, temple, or other spiritual community) Do you participate in a faith community? If so: Worship community Location Attendance per month (circle) 0 1 2 3 4 5+ Childhood religious affiliation What would you like your counselor to know regarding your spiritual/religious experiences or needs? Life Experiences List three significant events in your life and how they were significant.