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 Living Well Cancer Resources.

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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 Living Well Cancer Resources 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. Living Well counselors are available for appointments during​ normal business hours, Monday through Friday, with some evening hours available. Living Well 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. Living Well is able to provide an individual with a maximum of 20 sessions. Each session will be 50 minutes in length. Please provide 24 hours advance notice if you need to miss an appointment. Email is best for quick, administrative needs such as canceling or rescheduling an appt.  If you need to discuss something in more depth with your counselor, please reach out via phone or wait until your next scheduled session.

    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. Living Well 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 Living Well’s Director.

    Referrals. Living Well Cancer Resources 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 your allotted 20 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 Living Well 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”.
    Living Well 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'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 Living Well 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.

    Telehealth Services
    In addition to office-based appointments, Living Well provides individuals the option to conduct counseling sessions via telehealth, either as phone-based appointments or video based appointments utilizing the HIPAA compliant platform, Microsoft Teams.

    There are possible limitations to telehealth care, including:
    • Sessions may lack video and/or audio cues, which may cause misunderstanding
    • Sessions may have disruptions due to the service and quality of technology used
    • Sessions are not appropriate if you are having a crisis, acute psychosis, or suicidal/homicidal thoughts. In such instances your therapist will talk with you about a higher level of care outside of Living Well and when symptoms have stabilized, resuming care at Living Well through in-person sessions in place of telehealth based sessions
    There are also potential risks unique to telehealth counseling. When technology is used for communication of any kind, there is always the risk it may be forwarded, intercepted, circulated, stored, or even changed and the security of the devices used may be compromised. Although we make every reasonable effort to protect the privacy and security of all electronic communication we have with you, it is not possible to completely secure the information. With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may have access to any technology, devices, or any other device you know is safe. You are responsible for reviewing the privacy sections and agreement forms of any application and technology you use. Please contact us with any questions that you may have on privacy measures.

    Client responsibilities for telehealth appointments include:
    • Avoid the use of mind-altering substances prior to or during session
    • Dress appropriately during session (shirt and pants required)
    • Not bring any weapons of any kind to session
    • Not record sessions without first obtaining the therapist’s approval
    • All telehealth clients should:
      • Be in an area that is safe and provides privacy
      • Be in an area that is appropriate for a web-based session
      • Not have anyone else in the room unless you first discuss it with your clinician
      • Not conduct other activities while in session, such as driving
      • Be located within the state of Illinois or in a state in which the treating professional is licensed
      • If a minor, have a parent or guardian with them at the location/building of the telehealth session, unless otherwise agreed upon with the therapist and client
    So that your clinician can get you help in case of an emergency and for your safety, the following are important and necessary:
    • You, the client will inform your clinician of the location in which you will be consistently during your sessions, and you will inform him/her if this location changes.
    • You, the client, will identify on your client intake form a person whom your clinician can contact in the case that he/she believes you are at risk (emergency contact)
    • Depending on the assessment of risk, you, the client, or your clinician may be required to verify that your emergency contact person is able and willing to go to your location in the event of an emergency, and if your clinician deems necessary, call 911 and/or transport you to a hospital.
    In the event of technology failure, your counselor will make every effort to get in touch with you through an alternate means of communication.
    • For video sessions: we ask you to end and restart the session. If you are unable to reconnect within five minutes, your counselor will call and/or email you at the phone number and/or email address you listed on your intake paperwork. Please have this phone and access to your email account available to you during session time.
    • For phone sessions: your counselor will attempt to call you back at the same number if the call is disconnected. If you and your clinician are unable to connect again on the phone, the clinician will send you a message via email to follow-up.
  • Counseling Intake Questionnaire

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  • Symptom Inventory

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