Today's Date

Are you
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Are you
Please selectAdultChild

Name (First Name, Middle Name, Last Name)

Date of Birth

Age

Social Security (Optional)

Address

County of Residence

If client is Child, Parent Name

Date of Birth:

Age

Place of Employment / School

Home Phone

May we call you here?
Please selectYesNo

Cell Phone

May we call you here?
Please selectYesNo

Work Phone

May we call you here?
Please selectYesNo

Email Address

Ethnicity
Please selectNative American / Alaskan NativeAsianBlack / African AmericanHispanicMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteOther

Primary Language
Please selectEnglishSpanishOther

Are you an active service member or a Veteran?
Please selectYesNo

Are you a family member of an active service member or a Veteran?
Please selectYesNo

Were you referred by the Veteran Resource Center?
Please selectYesNo

Why are you seeking counseling?

Who referred you to Family Support Services?

Have you ever been
Please selectHitThrownSlapped

By Whom?

How many times?

Most recent date

Have you ever been
Please selectSexually MolestedSexually Abused

By Whom?

How many times?

Most recent date

Acknowledgement and Understanding of Client Agreement, HIPAA Privacy Practices and Counseling Informed Consent

, have read and understand Family Support Services’ Client Agreement, the HIPAA Privacy Practices and Counseling Informed Consent forms and have received a copy of both.
It is my understanding that will be involved in
counseling/therapy/educational services at Family Support Services and that it is my right to terminate received services at any time.
By signing below, I agree to abide by the Client Agreement, HIPAA Privacy Practices and Counseling Informed Consent forms.

By signing below, I agree to abide by the Client Agreement, HIPAA Privacy Practices and Counseling Informed Consent forms.
Client Name

Guardian Name (if client is under 18 years)

Psychosocial Assessment:
Check any topics you would like addressed in counseling
AbortionAlcohol / DrugsAngerAppetite ChangeAssertivenessBothersome HabitsCareer DecisionsConfusionOtherDecision MakingDelusionsDepressionDivorceFamily ConflictFear of FutureHallucinationsLegal IssuesLonelinessLoss / Grief / DeathMotivationObsessionsPhysical HealthPregnancyRelationship IssuesSchool AnxietySelf-ConfidenceSelf-ImageSexual AssaultSexualitySleepStress / AnxietySuicidal ThoughtsWeight Loss / Gain

Work or School Schedule

Monday Schedule

Tuesday Schedule

Wednesday Schedule

Thursday Schedule

Friday Schedule

Please list all the people currently living in your household

Family / Social History:
Born & Raised (Location)

Number of Siblings

Brothers

Sisters

Your place in the family birth order (1st, 2nd,)

Total children in family

Who primarily raised you?

Describe marriage or significant relationships

Number of children you have

Current living situation

Significant losses, including deaths, divorce, or incarceration (including dates):

Highest Level of Education
Elementary SchoolHigh School Not completedGEDHigh School DiplomaSome CollegeBachelor’s DegreeMaster’s DegreePh.D., MD, or Other D

Hobbies

Spiritual Beliefs

Who do you turn to for support (friends, family, etc)? Please list their names and relationship to you

Have there been any serious illnesses, injuries, emotional problems in the immediate family, including yourself?
Please selectYesNo

If Yes, please describe

What medications are you presently taking? (include home remedies and over-the-counter drugs such as aspirin, etc.)

Substance Use:
Has your alcohol or drug use negatively impacted your (life family, work, finances)?
Please SelectYesNo

Have you ever had a drug/alcohol related blackout?
Please SelectYesNo

Do you have any family members with a drug or alcohol addiction?
Parent/Step-ParentSiblingGrandparentFriendChildOther

If Other, please explain

History of Substance Abuse:
Alcohol

Cigarettes

Cocaine

Downers (Benzodiazepines, Xanax, Valium, etc.)

Ecstasy

Heroin

Inhalants

LSD (Acid)

Marijuana or THC products

Methamphetamines – Crank, Crystal, Ice, Speed

Mushrooms

PCP

Synthetic Marijuana (K2, Spice)

Other

Desire to Harm Self or Others:
Current desire to harm self?

Have you attempted to harm yourself in the past?

Current desire to harm others?

Have you attempted to harm others in the past?

Counseling History
Have you had any previous counseling?
Please selectYesNo
If yes: where, when and name of counselor:

What changes do you hope to see in your life from participating in therapy?

Who referred you to Family Support Services?

Full name of person completing questionnaire if different from client:

Client Financial Agreement:
Effective March 1st, 2021, Family Support Services (FSS) has put into place new policies regarding the intake process, no-shows and late cancellations, as well as our new system to collect and safely store debit/credit cards for all clients. These measures have been taken to better serve you and allow FSS to continue to provide optimum care for all those we serve. Listed below are the policies and their associated fees. If you have any questions, please feel free to contact our office at 806-342-2500 and ask to speak to a billing associate.

Intake Process: As part of your intake process, our Intake Coordinator will collect and verify information regarding your insurance, life history, basic demographics and other vital information. For individuals seeking counseling, there is a $20 fee for this service.

No Shows/Late Cancellations: Appointments are created in advance for all counseling services so that counselors can set time for your session on their calendar. All counselors require notification of cancellation within 24 hours prior to the set appointment. If cancellation is not made 24 hours in advance (or at all), a late cancellation fee of $50.00 will be charged. This late fee will need to be paid at time of next scheduled appointment.
If a client has two back-to-back late cancellation or no-show, they will not be able to schedule another session with counselor until the balance is paid in full.

Debit/Credit Card Storage: FSS requires that a debit or credit card is kept on file for payment of services. FSS will process payments within 24 to 48 hours after your counseling session. If you wish to pay with cash, check, money order or another credit/debit card, please contact our office one day in advance of your session to make arrangements with our billing department.

Declined or Rejected Debit/Credit Cards: If the card on file is rejected or declined for payment, a FSS staff member will attempt to make contact with you via email or phone in order to gather new payment information. If contact is unsuccessful, the payment will be required prior to the next appointment. If updated debit/credit card information is not provided and accumulates to two unpaid sessions, future scheduling and provision of counseling sessions will be paused until payment arrangements are made.

* Please note, the fees described above do not apply to Medicaid clients.

Client Acknowledgement:

, agree to the above statements regarding the financial policies of Family Support Services. I understand that payment is required at time of in-take appointment. If there are any questions or concerns regarding my account, I will contact the billing department at 806-342-2500. I also understand that my counselor will not be able to make any payment arrangements on my behalf toward my account.
I agree to provide a debit/credit card for Family Support Services to save in their secure software system to process fees associated with my intake, counseling fees, late cancellations, and/or no-show fees.

I also acknowledge it is my responsibility to inform the FSS billing department if my debit/credit card information has changed. I acknowledge that FSS will suspend my counseling services until my balance is paid.

I fully understand that that not all of the costs of services provided by FSS may be covered by insurance or other means, and I agree that I may be responsible for the cost of the services I receive, including BIPP classes, WAV classes, counseling sessions, and supervised visitations, that are not covered by insurance, Medicaid or other programs. I understand that FSS may discontinue my services if payment is not received for services that I have received.

Signature (type name)

Today's Date

Debit/Credit Card

CVV

Billing Zip Code

Expiration Date

Client Agreement:
We want your experience at Family Support Services to be as beneficial as possible. It is helpful to know exactly what to expect and how our agency works.

If counseling has been court ordered, counseling cannot begin until a copy of the court order has been provided to Family Support Services. (if required)
Confidentiality

Confidentiality means keeping private your identity and the information you share with your counselor and/or other group members. On occasion, other Family Support Services employees or interns will have access to your file for agency teaching, supervision, research, treatment and administrative purposes. Interns or agency staff will also, on occasion, observe session(s). Furthermore, auditors from outside this agency may also access your records. Any person observing a session, group or your file is required to sign a statement, requiring them to respect your confidentiality.

Exceptions to Confidentiality
• Your records could be subpoenaed by a court of law.
• If you are threatening to harm yourself or someone else, we will contact the appropriate agency or authority for your safety.
• We must report suspected neglect or abuse of children, the handicapped or the elderly (we are required by law to notify the appropriate protective service. We encourage you to report any incidents personally).
• Reports will be sent to referring agents from the legal system, as applicable (e.g., judge, district or county attorney, probation officer, or child or adult protective services caseworker).

Insurance Policy

Family Support Services will accept assignment and bill on insurance policies. You will be expected to meet your deductible. Until the deductible is met, you will receive a monthly statement for any owed balance. You are responsible for any out-of-pocket expenses not covered by your insurance. Once you have met your deductible, you will be expected to pay the co-pay at each visit according to your insurance policy. A payment plan will be available if this creates a financial hardship for you.

If incomplete insurance information, inaccurate insurance information or change of insurance without notification results in non-payment of claim or if for any other reason insurance refuses to pay, you will be responsible for payment of entire session fee.

Cancellation or No-Shows

We require a 24-hour notice for all cancellations. This courtesy gives us the opportunity to schedule other waiting individuals. Cancellations with less than a 24-hour notice will result in a charge of $50.00 (fifty dollars).

In the event you do not show up for your scheduled appointment (no-show), there will be a charge of $50.00 (fifty dollars) which you will be responsible for paying before your next scheduled appointment.

Cost of Service

We are able to provide services to families and individuals by accessing United Way Funds, agency funds, contracts, and by accepting third party payment sources such as insurance assignments and client fees to fund the services.

We have a sliding scale fee based on gross household income (the amount before taxes or any deductions are taken out). If you are a self-pay client, your fee will be set at your intake appointment, based on your gross annual household income. Fee is due at the time of service. We require written income verification to be in your file. The verification must be updated every year based on the original intake date. Any change in circumstances must be reported as soon as possible.

Assignment to Counselor

Following an intake appointment, your case will be assigned to a counselor. You should expect to receive a call from a counselor. If you have not received a call you should contact the Director of Behavioral Health and Wellness, Kathy Tortoreo, at 342-2500.

After-Hours/Weekend Calls

Family Support Services is not an emergency facility. You may access our 24-hour hotline at (806) 374-5433 or Texas Panhandle Center’s Crisis Line at (806) 359-6699 or 1-800-692-4039. If you have an emergency after office hours or on weekends, go to your hospital emergency room or call 9-1-1.

Client/Guardian Name

Today's Date

HIPAA NOTICE OF PRIVACY PRACTICES Family Support Services Effective Date:
September 1, 2003
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS CAREFULLY

If you have any questions about this notice, please contact Kathy Tortoreo, Privacy Officer of Family Support Services at 806-342-2500 or ktortoreo@fss-ama.org.

Our Pledge Regarding Health Information:

Family Support Services understands that information about your health and health care is personal. We pledge to protect this confidential information about you. Family Support Services creates a record of the services and care you receive from us. This record is necessary to assure you of high quality services and is essential to comply with certain legal requirements. This Notice of Uses applies to all of the records of your care while at Family Support Services. The following notice tells you how we use and disclose health information about you. It also describes your rights to your information and certain obligations we have regarding the use and disclosure of your health information.

Our Legal Duty:
• We are required by applicable federal and state law to maintain the privacy of your health information.
• We must provide you with a copy of this notice in regard to our legal duties and privacy practices.
• We must follow the privacy practices described in this Notice while it is in effect.
• We reserve the right to change our privacy practices at any time. You will be notified of
changes in our privacy practices.

How We May Use and Disclose Health Information About You:
• For Treatment. We may use or disclose your health information to provide you with health care treatment or services. This information may be shared with therapists, supervisors, and other staff of Family Support Services participating in your care.
• For Payment. We may use and disclose your health information so that your treatment and services you receive from us may be billed to and payment collected from you, an insurance company, or other third party. We may also tell your health plan about services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
• For Health Care Operations: Information about you may be used or disclosed for the operation of our services. Health care operations include quality assurance and improvement activities, case management, evaluating the competence or qualifications of our staff, accreditation, licensing, conducting training programs, and supervision.
• Appointment Reminders: We may use and disclose personal information about you to contact you as a reminder that your have an appointment. Please let us know if you do not wish to have us contact you concerning your appointment or if you would like us to use a different telephone number or address for your reminder.
• Your Authorization: You may give us written authorization to disclose your health information to anyone for any purpose.
• As Required By Law: We may use or disclose your health information when we are required to do so by law.
• To Avoid a Serious Threat to Your Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person, if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the victim of other crimes.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose personal information about you in response to a subpoena, discovery request, or other lawful process. We will make a reasonable effort to contact you in regard to these requests.

Client rights:
• Right to Inspect and Copy: You have the right to inspect and copy health information that may be used to make decisions about your care. You may submit your request in writing to Kathy Tortoreo, Privacy Officer. If you request a copy of the information, we charge a fee for the costs of copying, mailing, or other supplies and services associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed. Family Support Services will appoint a health care professional to review your request and the denial. We will comply with the outcome of the review.
• Right to Amend. If you feel that the information about you is incorrect or incomplete, you may ask us to amend the information. You have this right to amend as long as we store your record. To request an amendment, please submit your request in writing to Kathy Tortoreo, Family Support Services Privacy Officer. This request must be on one page of paper and must provide a reason that supports your request for an amendment.
• Right to an Accounting of Disclosures. You have the right to request a list accounting for any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and health care operations as previously described. To request a list of disclosures, please submit your request in writing. A records fee may be charged for this list.
• Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this notice at any time. There is no charge for a copy of this Notice.

Changes to this Notice
We reserve the right to change this notice. This right extends to health information we already have about you as well as any information we will have in the future. A copy of our current notice will be posted in our agency.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. Please submit those to Kathy Tortoreo, Privacy Officer. You will not be penalized for filing a complaint.

You also have the right to contact the licensing board of the state of Texas if you believe you have been treated inappropriately or unethically. The complaint must be filed on an approved complaint form. You may contact them at:
Behavioral Health Executive Council https://www.bhec.texas.gov/discipline-and-complaints/index.html

Other Uses of Health Information
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us with permission to use or disclose health information about you, you may revoke that permission, in writing, at any time.

Acknowledgment of Receipt of this Notice
We request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgement will be kept on file in our offices.

Counseling Informed Consent
What to expect:

The purpose of meeting with a counselor or therapist is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life.
You may be here because you wanted to talk to a counselor or therapist about these problems. Or, you may be here because a family member, friend, doctor or someone else had concerns about you. When we meet, we will discuss these problems. I will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about the issues that are bothering you. Your counseling services at Family Support Services will be conducted by a licensed professional, i.e. a licensed professional counselor, licensed clinical social worker, a licensed marriage and family therapist, or a licensed intern of one of those professions.

Counseling may be conducted with an individual, couple, or family. Counseling is a healing art; however, part of healing in general can be painful. Discussing painful memories can trigger those emotions. Your therapist will help you process those emotions. For this reason, it is important to keep your appointments and stick to your therapeutic plan. We want you to have healing!

If you find you are unable to continue participating in counseling services, it is important you communicate with your therapist, as opposed to just quitting services. Your mental and emotional safety are important; therefore, we will want to help you plan for success. If you feel like our counseling sessions are not meeting your goals, your input will be welcomed.

For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling. As a general rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether or not I have your permission. I have listed some of these situations below.

Confidentiality cannot be maintained when:
• You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. I must take steps to inform another mental health professional and/or law enforcement of what you have told me and how serious I believe this threat to be. I must make sure that you are protected from harming yourself.
• You tell me you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation I must inform the person who you intend to harm.
• You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, I will need to use my professional judgement to seek out resources for your safety.
• You tell me about situations involving the abuse-physical, sexual or emotional of a child, elderly, or disabled person. In this situation, I am required by law to report the abuse to the Texas Department of Family and Protective Services.
• You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Although I have agreed to keep information confidential I may find certain information important to discuss with family members or significant others in your life. In these situations, I will encourage you to tell that person and will help you find the best way to tell them.

I look forward to working with you on your path to personal growth.

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