Court-Related Matters. Nurses who are requested by the Medical Center to appear as a witness in a court case during their normal time off duty will be compensated for the time spent in connection with such appearance.
Court-Related Matters. I understand that my counselor will not willingly testify in any court proceeding as this role, more often than not, jeopardizes the therapeutic relationship. However, if required by law to appear and/or testify, I understand that I will be charged $250.00 per hour for time spent in activities preparing for a courtroom appearance. I also understand that I will be charged $800 per courtroom appearance – regardless of the time spent in the courtroom and regardless of whether my counselor is able to testify that day or not. Payment for courtroom appearance will be required prior to my counselor’s appearance in court. Initial here I understand and agree to all of the policies listed above, and to meet all financial obligations. Signature of Client or Legal Guardian: Date: Print Name: Address: Xxxxx Xxxx Xxxxx MSW Individual, Couples and Family Psychotherapist CLIENT INFORMATION SHEET-- Children Child’s Name: (First, Middle, Last): Address: Home Telephone: Cell Phone: Date of Birth: Age: Name of School/ Grade: Mother/Guardian: Father/Guardian: Address: (if different than above) Address: (if different than above)
Court-Related Matters. Nurses who are requested by the Medical Center to appear as a witness in a court case during their normal time off duty will be compensated for the time spent in connection with such appearance. 112.9 Educational Leave of Absence. The purpose of an educational leave of absence is to provide an extended period of unpaid leave to participate in a degree seeking formal education program. After one (1) year of continuous employment, the nurse may request up to six (6) months for an educational leave of absence. An Educational Leave of Absence is unpaid. Use of paid time accruals may be required before going to an unpaid status. A nurse on an unpaid educational leave of absence is not eligible for benefits and does not accrue benefits. A nurse can contact the HR Service Center for information about benefit continuance on a self‐pay basis. The Employer reserves the right to grant or deny an educational leave of absence. The granting of an Educational Leave of Absence, regardless of whether the nurse was in a paid or unpaid status, does not guarantee return to employment or to the nurse’s original position or schedule. Nurses returning from an Educational Leave of Absence may apply for any available vacancy for which they are qualified. If the nurse is unable to secure a position at the end of his/her leave, it will be treated as a voluntary resignation. It is the responsibility of the nurse to contact their Department Director/Manager at least four (4) weeks prior to the expiration of an Educational Leave of Absence. It is the responsibility of the Department Director/Manager to notify Human Resources in writing within one (1) working day when the nurse returns from an Educational Leave of Absence. Failure to report availability for work within three (3) calendar days after the expiration of any leave of absence is considered a voluntary termination. The nurse must apply for a leave of absence extension prior to the expiration of the original leave. Appropriate documentation must accompany the leave extension request.
Court-Related Matters. I understand that my counselor will not willingly testify in any court proceeding as this role, more often than not, jeopardizes the therapeutic relationship. However, if required by law to appear and/or testify, I understand that I will be charged $250.00 per hour for time spent in activities preparing for a courtroom appearance. I also understand that I will be charged $800 per courtroom appearance – regardless of the time spent in the courtroom and regardless of whether my counselor is able to testify that day or not. Payment for courtroom appearance will be required prior to my counselor’s appearance in court. Initial here I understand and agree to all of the policies listed above, and to meet all financial obligations. Signature of Client or Legal Guardian: Date: Print Name: Address: Xxxxx Xxxx Xxxxx MSW Individual, Couples and Family Psychotherapist CLIENT INFORMATION SHEET Name: (First, Middle, Last): Address: Home Telephone: Cell Phone: Date of Birth: Age: Client Information Spouse Information W Telephone: W Telephone: Cell Phone: Cell Phone: Profession: Profession: Email: Email: Primary Care Physician Name: Is there information that would Address: be helpful for me to obtain from your PCP? Yes No Phone Number: Please list the members of your household: (name, age, relationship) Referral Source How did you hear about Xxxxx Xxxxx? Please include the address for your referral source if you have it: Are you taking any medications? Yes No If yes, please list the medication and dosage. Have you ever received psychotherapy services in the past? Yes No If so, with whom? Please list any therapists and their phone numbers who are currently involved with you or your family: Have you received medical or psychological diagnoses in the past? Yes No If yes, please list diagnoses. Please state the nature of your concerns: Family History (Please check items that apply.) UK = Unknown, M=Maternal Side of Family, P=Paternal Side of Family, Ch: Your children Diagnosis Yes No UK M,P,C,S Diagnosis Yes No UK M,P,C,S Depression Metabolic Disorder Anxiety Heart Disease Bipolar Disorder Allergies ADD/ADHD Asthma Sleep Disorder Sinus Infections Autism/Xxxxxxxx’s/ PDD Obsessive - Compulsive Disorder Tourette’s Sensory Integration Genetic Disorder Substance Abuse Fragile X Other: Xxxxx Xxxx Xxxxx MSW Individual, Couples and Family Psychotherapist NOTICE OF PRIVACY PRACTICES OF
