Counseling Services Agreement and Intake Questionnaire-profile-image

Counseling Services Agreement and Intake Questionnaire

Please take a moment to complete this confidential agreement and questionnaire for counseling services. Your information will not be shared with anyone outside of the LivingWell Cancer Resource Center.

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  • We realize that starting counseling is a major decision and you may have many questions. This document is intended to help answer some of those questions for you by informing you of our policies, State and Federal Laws, and your rights. Our Staff. All counselors at LivingWell Cancer Resource Center have earned a Master’s degree and are licensed by the State of Illinois as a mental health clinician. A copy of your counselor’s Professional Disclosure Statement is available to you upon request. Office Hours and Emergencies. LivingWell counselors are available for appointments during normal business hours, Monday through Friday, with some evening hours available. LivingWell is not a crisis center and is not equipped to provide emergency or crisis counseling. If you are experiencing a medical or mental health crisis or emergency, please call 911 or go to the nearest emergency room. Appointments. LivingWell is generally able to provide an individual with 12-16 sessions, with each session being 50 minutes in length. Please provide 24 hours advance notice if you need to miss an appointment. If you need to contact your counselor to cancel, reschedule or confirm an appointment, the best way to do so is by phone as we cannot guarantee the confidentiality of email. Benefits and Emotional Risks. The majority of individuals who participate in counseling services benefit from the process. However, during the counseling process, you may find yourself at moments disclosing very personal information that may move you to feel anxious or uncomfortable. This is normal. Although counseling is intended to improve your quality of life, in its early stages it is possible to experience an increased intensity of thoughts and feelings before experiencing relief in the later stages of the process. If this occurs, please do not hesitate to discuss this issue or any issues that arise as a result of the therapeutic process with your counselor. Coordination of Care. If you have been in counseling or psychotherapy in the past and/or are currently receiving other relevant services elsewhere, your counselor may find it important or beneficial to communicate with the other professionals involved in your care and/or receive copies of their records. In the event that you and your counselor deem it important to communicate with these professionals, your counselor will ask you to sign a Release of Information form so they can communicate with those individuals. Client Rights. As a client, you are in complete control and may end the counseling relationship with your counselor at any time. If you choose to end the counseling relationship, your counselor may ask that you participate in a termination session. You also have the right to refuse or to discuss modification of any counseling technique or suggestions that you believe might be harmful. LivingWell counselors render counseling services in a professional manner consistent with accepted ethical standards. If at any time for any reason you are dissatisfied with the services you are provided, please let your therapist know. If you are not able to resolve your concerns with your therapist, we encourage you to report your complaints to LivingWell’s Director. Referrals. LivingWell Cancer Resource Center offers counseling that focuses on the impact of a cancer diagnosis. Some clients achieve their goals in only a few counseling sessions, whereas others may require time that extends beyond what you and your counselor are able to address in 12-16 sessions. If you and/or your counselor believe a referral is needed, your counselor will provide you with information on other mental health professionals, agencies, programs and/or people in the community who may be able to assist you in properly addressing your needs. Confidentiality. All of your counseling sessions are confidential. This means that no information will be released to persons or agencies regarding the fact that counseling has been received or the nature of the concerns without written consent unless one of the following conditions is met, which, by law, necessitate the breaking of confidentiality and notifying the appropriate individuals or agencies: 
 If you provide information that informs your counselor that you are in danger of harming yourself or others Information you and/or your children report about physical/ sexual abuse or neglect, the abuse or neglect of a disabled persons or elder abuse or neglect When the counselor is a defendant in a civil, criminal, or disciplinary action rising from the therapy or when information regarding your status as a client or information shared in your sessions is subpoenaed or ordered to be released by a judge in a court of law. If group counseling is provided, neither the clinician nor LivingWell can be responsible for any breach of confidentiality on the part of a group member. All members are advised of the expectation of confidentiality and instructed to honor the concept of “what happens in the group stays in the group”. LivingWell is a HIPAA mandated organization and counselors strictly adhere and are compliant with all standards. If you wish to see a copy of Northwestern Medicine/LivingWell’s HIPAA policy, it will be available to you upon request. Counseling Relationship. Your relationship with your counselor is professional in nature. As such, your counselor may not interact with you on personal social media or accept gifts. Additionally, in adherence with confidentiality, in the event that you see your counselor in a setting outside LivingWell or outside of a professional context, your counselor will not initiate acknowledgment of you as your counseling relationship is confidential. You are, however, welcome to approach your counselor or initiate conversation.
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  • Counseling Intake Questionnaire

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  • Symptom Inventory

  • This field is for validation purposes and should be left unchanged.