CLINICAL RECORD FORM

ADMINISTRATIVE & SELF-REPORT INFORMATION (May Be Completed by Patient)

Patient: ___________________________________________

Date of Birth: ___/___/___

Age:

Address:
City: _________________________________________________ State: ________
Telephone:Home: (____) ____________

Cell: (___)

Zip:

(email) _______________

Health Plan or other Patient ID#:

_________________________________________________________________
Employer/School:
Sex: Male

Female

Marital Status: Married

Single

Emergency Contact: ___________________________________________

Divorced

Widowed

Telephone: (____) ___________

Parent/Guardian (if relevant): Name:

Address: _____________________________________________________

Telephone: (____)

Current Medical Conditions:

Previous Counseling:

Previous Mental Health Hospitalizations:

Current Medications, Herbal Supplements & Vitamins (Daily Dose, Start Date, Name of Prescriber):

Allergies/Adverse Reactions to Treatment:

Primary Care Physician Name:

Address: ______________________________________________________

Telephone: (____)

Reason for Seeking Evaluation Today:

Patient Signature: __________________________________________________________ Date: _______________

Mental Health

Self-Assessment Screening
In the past 90 days, have you experienced problems or changes with the following areas ?
Family or Friends yes
Housing yes

no

no

Employment yes

no

Medical illness or problems accessing health care yes

Legal Status/ Probation yes
Substance Abuse yes

no

no

Hospitalizations (Medical or Mental Health) yes

Problems Sleeping yes
Feeling Sadness yes

no

no
no

Obsessive Thoughts yes

no

Feeling the urge to Isolate yourself yes

Fear or Paranoia yes
Hearing Voices yes
Seeing things yes

no

no

Unusual Thoughts yes

Irritability yes

no

no

Problems with Appetite yes

Crying Spells yes

no

no
no

no
no

Suicidal thoughts yes

no

Urges to harm self or others yes

Aggressive behavior yes

no

no

Other : Describe_____________________________________________________________________________
Please list any additional information you feel is needed to help you in reaching your treatment goals.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Informed Consent to Treatment

You have taken the important first step to pursue counseling with Chikeitha Owens, M.A.,
Licensed Professional Counselor. I realize that starting counseling is a major decision, and you may have
many questions. This document contains valuable information about my professional services, state and
federal laws, and your rights. If you have any questions about what is stated in this document or about
something that is not covered in this document, please ask me so that we can discuss your questions.
COUNSELING WITH CHIKEITHA OWENS:
I view counseling as a way to enrich your life. Counseling can improve your physical, mental, and
spiritual well-being as well as your relationships. You may have specific issues to address or just want to
enhance your day-to-day living. While some people believe that seeking out counseling signals
weakness, I wholeheartedly believe that seeking counseling for oneself exhibits tremendous strength.
Counseling can serve to further uncover your strengths and help provide strategies about ways to
employ them. I consider it an honor to be an empathetic, non-judgmental, objective presence in a
situation where you can be at your most vulnerable. Thank you for the privilege of providing you with
counseling.
I earned my Masters degree in counseling from Argosy University of Dallas, Texas. I am licensed by
Texas State Board of Examiners of Professional Counseling. My theoretical orientation is from an eclectic
approach using client-centered, cognitive-behavioral, and existential, among others. I incorporate mind,
body, and spirit in counseling. In addition, I view the individual as being part of a family, a community,
and other groups that can influence the clients experience.
PROFESSIONAL COUNSELING: I am bound by the rules and codes of the following organizations, and I
take these responsibilities seriously. The Rules of the Texas Board of Examiners of Professional
Counselors. The ACA Code of Ethics (2005) states The primary responsibility of counselors is to respect
the dignity and to promote the welfare of clients. A.1.a. (www.counseling.org). Please find the
remainder of these rules and code at the web sites provided. Professional counseling has been
scientifically shown to have many benefits such as solutions to specific problems, better relationships,
and improved health and welfare. However, there are no guarantees that your problems will be
remedied by pursuing services with me. You may experience unpleasant feelings. Growth is difficult, and
things may feel worse before they get better in our work together.
SERVICES OFFERED: I am experienced in counseling individuals, families, and groups. I provide
counseling to children, adolescents, and adults presenting with a wide range of issues. I do not
prescribe medication. If you or a family member requires services that I cannot provide, I shall assist
you in a referral, and with your permission, coordinate services with the specialty provider. In our initial
session(s), I will complete a brief evaluation by gathering information about your reasons for pursuing
counseling and take a personal history. After the evaluation session(s), I will be able to offer you some
first impressions of what our work together will include and a treatment plan to follow, if you decide to
continue counseling with me. We will work together to devise a counseling plan that offers reasonable
promise of success and is consistent with your abilities and circumstances. We will regularly review the
plan to ensure its continued viability and effectiveness. At any time, you have the right to terminate
counseling. If at any
time you would like a referral to another psychotherapist, I will provide one.

APPOINTMENTS AND CANCELLATIONS: A counseling session usually lasts 50 minutes. To avoid

being charged for a scheduled appointment, it must be rescheduled or canceled at least 24
hours in advance.
A missed appointment is a lost opportunity for both client and counselor. The counselor has
reserved that time for the client. Other clients have not had access to that appointment time because it
was held for you. In addition, your counselor considered that appointment time an important part of
your counseling. While unforeseen emergencies do occur, please make every effort to keep your
appointment as scheduled. When, on occasion, I will be unavailable for appointments, I will make every

attempt to inform you of this in advance. If I will be unavailable for an extended time, I will provide you
with the name of a colleague to contact, if necessary.
Email communication can be a convenient means of setting appointment times. You may not hold
Chikeitha Owens liable for any breach of confidentiality that results from the use of email
communication. For appointment purposes my email address is cowens007@gmail.com
_____________________________________ ______________________
Signature Date
PROFESSIONAL FEES & PAYMENT: $115 for initial 50-minute session and $100 for each
subsequent 50-minute session. I do negotiate fees on a sliding scale based on your familys gross
income and size. Virtual Therap(Video, Phone, Email/chat, Journal) is also available but is cash only and
insurance is not accepted.
Payment by cash or check is due at the time of service (I do participate in Third Party
Billing, all co-pays are due at the time service is rendered). Moreover, If you would like to submit
a receipt to your insurance company for reimbursement, please let me know as I will need to provide a
mental health diagnosis for insurance purposes. Your signature giving me permission to communicate
with your insurance provider means that your counseling is not confidential. Your insurance provider will
also determine how many sessions it will cover for the diagnosis. In addition, there are some mental
health services that many insurance providers do not cover. It is your responsibility to check with your
insurance provider prior to your appointment to determine if services provided by me will be covered.
Telephone consultation can occasionally be useful. There is no charge for brief phone calls.
Longer/frequent ones may be charged at a rate of $100 per 50 minutes and pro-rated based on the
length of the call. I will notify you if you will be charged for your calls. Telephone calls with referral
sources, family members, or others with whom you wish me to speak on behalf of your treatment needs
are charged in the same manner when they are lengthy, frequent, and/or numerous.
I understand that if counseling services are being rendered under a contractual agreement that the
therapist has with my insurance company that the above rates do not apply to my situation. (All copays or deductibles are due at the time service is rendered)
I understand that if counseling services are being rendered under a contractual agreement that the
therapist has with DFPS or IMHS or any other agency that the above rates do not apply to my situation.
I understand my cost per session is $______ and I have received a copy of my fee schedule.
_____________________________________ ______________________
Signature Date
COORDINATION OF TREATMENT:
CONFIDENTIALITY: Records are maintained on each client. Records may contain the following:
identifying information; session notes; any reports from other professionals regarding your treatment;
any correspondence or other materials that you send to me; copies of any correspondence about you
that I send to others. These records are meant to be a working
document to both reflect and guide your therapeutic work. Your records are confidential and may only
be accessed by me.

Your records are confidential except in the following circumstances:

1) Should you choose to seek reimbursement for counseling from your insurance provider, I will
communicate about your counseling with your insurance provider;
2) I am mandated to report physical or sexual abuse of children;

3)
4)
5)
6)
7)

I am mandated to report threats of suicide or homicide;

If you sign a release of information for me to communicate with someone else;
Information necessary for supervision or consultation;
Information noted in the HIPAA Notice of Privacy Practice;
Information required by law.

____________________________________ ________________________
Signature Date
EMERGENCY SITUATIONS: While I will always try to return your call or e mail within 24 hours and
usually sooner, I am not an emergency mental health service. If you experience an emergency, you
should call 911 or go directly to your nearest emergency room.

NOTICE OF PRIVACY PRACTICES AND CLIENTS RIGHTS: I/we have read and received a copy of the
HIPAA Requirements: Notice of Privacy Practices and Client Rights documents. You have the right to
report violations to the Texas State Board of Examiners of Professional Counselors, 1100 West
49th Street, Austin, Texas, 78756-3183; (512-834-6658).
How would you prefer to be contacted?
Home phone___________________________________________
Cell phone___________________________________________
Work phone___________________________________________
Other___________________________________________
I often use text messaging as a way to sometimes remind about appointments. Please check
this box if you consent to text messaging.
_____________________________________ ________________________
Signature Date

ACKNOWLEDGEMENT
By signing this disclosure and consent statement, the client acknowledges having been informed of
his/her rights and
responsibilities under regulatory laws for counselors in Texas. In addition, the client acknowledges
he/she has read and understands the administrative policies for this counseling office.
______________________________________________ _________________________
Signature of client Date
______________________________________________ _________________________
Signature of Spouse/Guardian Date
______________________________________________ _________________________
Signature of Counselor/Therapist Date
CONSENT FOR TREATMENT OF MINORS: Clients under 18 years of age who are not emancipated and their guardians should
be aware that the law allows parents to examine their childs treatment records unless I believe that doing so would endanger the
child, or we agree otherwise. Because privacy in counseling is often crucial to successful outcomes, particularly with teenagers, it
is sometimes my policy to request an agreement from parents that they consent to give up their access to their childs records. If
they agree, during treatment, I will provide them

only with general information about the progress of the childs treatment, and his/her attendance at scheduled sessions. If the
child reveals something to me that I believe that child should tell the parents, I will request that the child tell the parent in my
presence. I will notify the parents if I believe the child is a danger to himself or others. The parent/guardian should sign below if
(s)he agrees with this statement.
I __________________________________ agree that _________________________________ may be treated by Chikeitha Owens, MA, LPC,
____________________________________ ________________________
Parent/Guardian
Signature Date

HIPAA REQUIREMENTS:
NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS DOCUMENT
THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
April 10, 2016
The law protects the privacy of communications between a client and a counselor. In most situations, I can only release
information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed
by HIPAA (Health Insurance Portability and Accountability Act of 1996). There are other situations that require only that you
provide written advanced consent. Your signature on the Informed Consent Agreement provides consent for those activities as
follows.
Use and disclosure of protected health information for the purposes of providing services: Providing treatment
services, collecting payment, and conducting healthcare operations are necessary activities for quality care. State and federal
laws allow me to use and disclose your health information for these
purposes as follows.
TREATMENT: I may use and disclose health information to:
1. Provide, manage, or coordinate care with your physician or other healthcare provider who is also treating you.
2. Ensure that I am providing the highest quality counseling, I may consult with other mental health providers. During such
consultations, I make every effort to avoid revealing the identity of my client. The other professionals are legally bound to keep
the information confidential. I will note all consultations in your records.
COLLECTING PAYMENT: If you are using your insurance for payment, it is necessary to disclose clinical information in order to
get an authorization for counseling sessions. If you would like to pay out of pocket and attempt to seek reimbursement for
counseling from your health insurance provider, I will disclose information to your insurance provider at your request. If you have
not paid for services at the time of your appointment as required, I may be forced to send you a bill which may include
information that identifies the client as well as other healthcare information.
HEALTHCARE OPERATIONS: I may have to disclose health information for both clinical and
administrative purposes, such as review of treatment procedures, review of business activities, certification, compliance, and
licensing activities.
OTHER USES AND DISCLOSURES WITHOUT YOUR CONSENT:
1. I am mandated to report the following to the appropriate authorities:
a. if I have reason to believe that a child has been abused, the law requires that I file a report with
the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, I may be required
to provide additional information;
b. if I have reason to believe that a disabled adult or elder person has had a physical injury or
injuries inflicted upon them, other than by accidental means, or has been neglected or exploited, I must report to an agency
designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional
information;
c. if I determine that a client represents a serious danger of violence to another, I may be required
to take protective actions. These actions may include notifying the potential victim and/or contacting the police, and/or seeking
hospitalization for the client. If such a situation arises, I will make every effort to fully discuss it with you before taking any action,
and I will limit my disclosure to what is necessary;
d. if I determine that you are a serious threat to yourself, I may be obligated to seek hospitalization
for you or to contact family members or others who can help provide protection;
e. if ordered by a court of law. If you are involved in a court proceeding and a request is made for
information regarding my professional services, such information is protected by the counselor-client privilege law, unless I am
ordered to release it by the court. If you are involved in or contemplating
litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information;
f. if a government agency is requesting information for health oversight activities, I may be
required to provide it for them;
g. if a client files a complaint or lawsuit against me, I may disclose relevant information regarding
the client in order to defend myself;
h. if a client files a workers compensation claim, and I am providing treatment related to the
claim, I must, upon appropriate request, furnish copies of all medical reports and bills.
Fortunately, these situations are unusual in my practice.

CLIENTS RIGHTS
1. You have the right to request where I contact you: home, work, cell phone, e mail, or some other means of your choice.
2. You have the right, by written authorization, to release your medical records to others. You also have the right to revoke that
release in writing. Revocation is not valid to the extent that I have already acted in reliance on your previous authorization.
3. You have the right to make a written request to inspect and copy your records. You will be charged $0.10 per page for copying in addition to any mailing costs.
Certain information in your record may be removed prior to your receipt if I feel it may cause harm to you..
4. You have the right to make a written request that I amend your records. I will have at least 30 days to decide whether to amend
your records as you have requested and in some instances may deny your request. If your request is denied, you have the right to
file a disagreement statement. Your disagreement statement and my response will be filed in the record.
5. You have the right to make a written request for an accounting of disclosures made of your health information with the
following exceptions: disclosure for treatment, payment, or healthcare operations; disclosures pursuant to a signed release;
disclosures made to the client; disclosures for national security or law enforcement purposes.
6. You have the right to make a written request to restrict uses and disclosures of your healthcare
information; however, I am not obligated to agree to your request. If I do not agree to your request, you have the right to
complain: first to me and secondly to the U.S. Department of Health and Human Services. I will not retaliate against you for such
complaints.
7. You have the right to receive changes in policies. If you have any questions or concerns about the foregoing, please
do not hesitate to ask me, and I will make every attempt to answer them.