Confidential Adult Individual & Couples Application ... · Individuals and couples in counseling...

Confidential Adult Individual & Couples Application

(Couples Need to Complete Two Applications)

Mental Health Counseling Services

Thank you for completing the application.

During this time of physical distancing, counseling sessions will be offered by phone and video conferencing.

When William Temple House physically reopens, counseling sessions will revert to on-site sessions at our Hoyt Street address.

We offer one of the most affordable mental health services in Portland, with fees ranging from $10 to $40 per session. These fees help us cover the cost of this important community service to keep it accessible for everyone. If you cannot pay for counseling at this time, we will waive your fee. For those who are able to pay, you may choose the amount that is appropriate for your circumstances. Payment can be made using a secure PayPal form on the counseling page of our website: williamtemple.org/counseling

William Temple House 2023 NW Hoyt St Portland, OR 97209 503-226-3021

William Temple House Counseling – Adult Application CONFIDENTIAL

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Informed Consent Professional Disclosure Statement

MUST READ & SIGN Mental Health Counseling.

Due to the Coronavirus pandemic, William Temple House is providing tele-health sessions to our mental health counseling clients. All sessions will be conducted by phone or by video connection. By signing this form, you consent to this form of service delivery. The following protocols will be operative until normal operations can be reinstated. We will be adhering to the following protocols for online contact.

Recommended Practices for Temporary Distance Counseling:

Clients can receive one session for 50 minutes on a weekly basis.

● At the beginning of each session, we will ask you if you have privacy in your current location; if not, we willrequest you move to a private location to receive counseling.

● We may use a method to ensure that we are actually talking to you, our client, such as a code word orpassword known only to you and the counselor, to indicate that you are talking to your counselor and that it issafe to talk.

● The counselor will obtain and document contact information for emergency referral resources that areavailable in the area where you are located. We may ask for an emergency contact for you in case of amental health emergency.

● Elicit from you and your counselor ways to limit the potential for breaches of confidentiality that can occur inyour home, e.g., family members overhearing discussion or entering the room.

● Lastly, we may ask for an alternate means of contact to reach you (i.e., phone, email), in case your digitalconnection does not work well and establish a plan to resume contact, e.g., how many attempts, by whatmethod(s).

I. How to make counseling effective:

A. Research shows that most people benefit from counseling. Individuals and couples in counseling maynot always achieve his or her wanted outcome. At times counseling may be difficult. In order toincrease the chances of counseling being successful the following are recommended:

B. Receive counseling on a regular basis.

C. Medication may be needed before counseling can be effective. You will need to work with yourmedical provider if that is the case.

D. Please do not arrive at a session while under the influence of alcohol, marijuana and/or other drugs.In cases where you need support for abstinence your counselor may ask you to participate in a 12-Step program or Smart Recovery. Both programs offer online meetings through Zoom andteleconferencing.

II. Confidentiality. Counseling is confidential. Material about you and your counseling will be kept confidentialin all situations with the exception of harm to self and others. Oregon law requires that we report:Child abuse, elder abuse, or abuse of the mentally ill or cognitively challenged. Under Oregon law child abuse includes physical abuse, neglect, sexual abuse and sexual exploitation including the exposure of children



to graphic sexual material such as pornography. Child pornography must be reported by law.

A. Domestic violence that occurs in front of children is a felony and will be reported.

B. Suicide and other forms of serious self-harm will be dealt with to protect the client. If hospitalization is required to ensure safety, steps will be taken towards that end.

C. In cases where the client threatens physical and/or sexual harm to another individual, the individual and the proper authorities will be notified.

D. By signing this form, you give permission to your counselor to consult. Most of our counseling is done by graduate student interns or post-graduate Counseling Residents. They are closely supervised and meet certain requirements before being allowed to practice. They will be sharing information within individual and group supervisors. Your name will not be used with off-site supervisors.

E. Couples and Families: Adhering to the accepted standard of the professional counseling community, one single file is kept for each couple and family in counseling. The William Temple House Counseling Department may be limited in its ability to protect the individual privacy of those named in couples and family case notes, if requested by a judge’s subpoena.

III. General Information

A. If you run into your counselor outside of William Temple House, for the sake of confidentiality and privacy, your counselor will not acknowledge you. Please do not see that as a personal rejection but as a protection of you. Counselors are not allowed to e-mail or participate in any social media sites with their clients, such as Facebook, even after counseling has ended.

B. Counselors are not allowed to initiate or receive hugs or other forms of touching with clients.

C. Counselors are not allowed to receive gifts from their clients.

D. Counselors are not allowed to meet with you off-site, attend events that involve you, or visit you if hospitalized.

E. All client chart notes have been prepared solely for use by William Temple House (WTH) personnel and its non-licensed Counseling Interns as part WTH’s educational, licensure, and/or professional training protocols.

F. The Chart Note:

a. Is the property of WTH.

b. Contains no mental health diagnoses.

c. Is not intended for use by any WTH client or third party in any civil, criminal, or administrativeproceeding of any kind.

d. Is intended to be used solely by WTH as part of its normal and usual educational and trainingprotocols.

e. Shall not be used by any WTH clients or third parties for any purposes other than their mentaland/or medical health and well-being, except as otherwise required by statute, administrativeregulation, or lawful court order.

f. These limitations have been fully explained to the client and he/she/they has/have consentedto them.

g. William Temple House provides counseling; we do not perform psychological or psychiatricevaluations for any purpose. We do not provide case notes and other records to GeneralAssistance, Social Security, Children and Family Services, for divorce and/or child custody, or



for any other legal issue. We will not give clients copies of their records. By signing this form, you waive your right to use our records in any matter of disability or legal process. However, under conditions of a bench subpoena we must release records.

G. If you are unable to make your appointment, please call and cancel ahead of time. If you fail to come to three appointments without canceling, your case will be closed.

H. When your counselor initially makes contact by phone, write down their name and phone extension number. If you need to contact your counselor, you need to know your counselor’s name.

I. In case of a mental health emergency call William Temple House during business hours. We will make every attempt to contact your counselor and have them contact you. After business hours call 911 or the Multnomah County Crisis Line (503.988.4888) or go to your nearest hospital emergency room.

If any problem should arise you can talk to your counselor’s supervisor at any time. Issues can also be discussed with the Clinical Director at 503-226-3021 (x1220). [do you want to include Dr. Bettis’ name so they know who the Clinical Director is?]

William Temple House reserves the right to deny counseling services.

Printed Name________________________________________________

Signature____________________________ Date_____ / _____ / ______

Do you prefer phone or video counseling sessions? Phone Video

If this application is for Couples Counseling, please provide partner’s name:

Name: _________________________________________________________



Client Information

Please print. Information on this form will help us better serve you. Thank you for completing the application.

Application Date______ / _______ / ________

Date of Birth______ / _______ / ________ Age___________

Last Name___________________First Name____________________Middle Initial_____

Gender Identification __________________ Preferred Pronouns____________________

Cultural/Racial/Ethnic Background ____________________________________________

Other Adults in Household___________________________________________________

Children in Household_______________________________________________________

Mailing Address___________________________________________________________

City____________________________ State_______ Zip code___________ - ________

How long have you lived in the Portland/Vancouver metro area? ____ Years ____ Months

Home Phone (______) _______ - ________ Cell Phone (______) _______ - ________

Work Phone (______) _______ - ________ Message # (______) _______ - ________

Email Address_____________________________________________________________

May we leave a phone message? Yes No

May we email you? Yes No

May we send you appointment reminders via text message? Yes No

Emergency Contact Information

Name_________________________________ Relationship to you___________________

Home Phone (______) _______ - ________ Work Phone (______) _______ - ________

Cell Phone (______) _______ - ________

Email address_____________________________________________________________



Please indicate when you are available for counseling (check all that apply):

Mon Tues Wed Thurs

10 am – 1 pm

1 pm – 5 pm

5 pm – 9 pm

For on-site counseling sessions: Counseling may take place on the 2nd floor. Are you able to climb stairs? Yes No

Do you have any accessibility requests? ________________________________________

Income Information Note: Income does not determine eligibility for services. Information provided is for demographics only and helps us obtain funding to provide services to you.

Your approximate annual income and sources:

$ ___________Work/Employment

$ ___________Significant other’s income

$ ___________Unemployment Comp.

$ __________ Workers’ Comp.

$ ___________SSI / Social Security

$ ___________SSDI / Disability

$ ___________Financial aid (college)

$ ___________Parental support to you

$ ___________ Pension

$ ___________ Savings

Do you have health insurance? If yes, which provider? _____________________________

Signature______________________________________ Date_____ / _____ / _______

(Without this signature we are unable to process your application.)



How did you hear about us? Please specify in the space provided below.

Referred by √ Specify

Academic institution?

Online search, Google, etc.?

William Temple website?

William Temple House brochure/flyer?

Other William Temple House program?

Facebook?

Friend?

Family member?

Church or clergy?

Mental health professional?

Cascadia Mental Health?

Life Works?

Substance treatment center?

Physician/Hospital?

Crisis line?

Shelter/Agency/Nonprofit?

Employer?

Self-referral (new client)?

Self-referral (returning client)?

Other?



Health Information and History

1. How would you rate your health?Excellent Good Average Poor Failing

2. List major childhood diseases, injuries or operations:

3. List past major adult diseases, injuries or operations in the last five years (e.g. the flu,mono, respiratory infection, urinary tract infection, etc.):

4. Select all present illnesses:Seasonal/Environmental allergies Frequent colds, infections, sinusitis Urinary tract infection Asthma or bronchitis A history of frequent cold/canker sores Acne, eczema, or skin rashes Hepatitis Exposure to environmental toxins (e.g. pesticides, heavy metals, industrial chemicals) Food allergies or sensitivities Inflammatory bowel disease or colitis Arthritis Autoimmune disorder (e.g. rheumatoid arthritis, hypothyroid disease, lupus) Cardiovascular disease, including a history of heart attack Type I diabetes Type II diabetes Alzheimer's or Parkinson's disease, or a family history of either ADD/ADHD

Autism Mood or behavioral disorders (depression, anxiety disorders, etc.) Consumption of more than 3 alcoholic beverages a week Consumption of marijuana more than 3X weekly Use of other drugs or medications not prescribed by a physician Sedentary lifestyle, or less than 30 minutes of exercise 3X weekly High blood pressure Migraines

Stroke Head injury Multiple sclerosis Cancer HIV Seizure disorder Fibromyalgia Covid-19 (Coronavirus) Other (please describe):



5. Have you been hospitalized for non-mental health related illnesses or injuries in the lastfive years?

No Yes If yes, how many times? ________

6. Do you have a medical care provider? No Yes

If yes, name of healthcare provider: _________________________________________

7. Have you ever attempted suicide? No Yes If yes, when: ____/_____/______

8. Do you have access to a gun? No Yes

9. What prescribed medications do you take?

10. What over-the-counter (non-prescription) or herbal medications do you take?

Weekly Daily

12. Do you smoke or consume cannabis?

I do not use cannabis Once a month or less Weekly Daily

11. How much and how often do you consume alcohol?

I do not drink Once a month or less



Please describe your chemical use history in the table below:

Method of use/amount

Frequency of use

Age of first use

Age of last use

Used in last 48 hours? Yes / No

Used in last 30 days? Yes / No

Alcohol

Barbituates

Cocaine

Crack

Meth

Heroin

Opiates/Pain meds

Tranquilizers

LSD, acid, mushrooms

Molly, Ecstasy, MDMA Marijuana,

medical or recreational

Inhalants

Other drugs

11. Sleepa. How long does it take you to fall asleep? __________________________________

b. How many hours do you sleep? _________________________________________

c. How often do you awaken and how long does it take you to fall back to sleep?

12. Eatinga. Have you gained or lost more than five pounds in the last year without dieting?

No Yesb. Do you follow a special diet? No Yes

13. Exercisea. Do you exercise? No Yes

If yes, please describe frequency and type: ________________________________



Personal History I. Relationships

1. Relationship status:Single Unmarried partnership Married Separated Divorced Widowed

2. Sexual orientation/preference ______________________________________________

3. Are you currently living with “significant other” adult? No Yes

a. If yes, how many months have you been living together? ___________

4. If married, how many times? __________

5. If divorced, how many times? __________

6. Do you have a best friend/confidant? No Yes

7. If you have children, please list below:

Child’s name Age Yes No Does child live with you? Does child live with you? Does child live with you? Does child live with you? Does child live with you? Does child live with you? Does child live with you?

II. Family History

1. With whom did you live until you were 18 years of age?

_____________________________________________________________________

2. Did either of your parents die before you were 18 years of age? No Yes

3. Did your parents ever divorce? No Yes

If yes, how old were you at the time of your parent’s divorce? _________

4. Did you have a stepparent before you were 18 years of age? No Yes



5. Were you adopted? No Yes If yes, at what age? ___________

6. Were you ever in foster care or a similar living situation? No Yes

7. Please list the names and ages of your brothers and sisters:

Name of Sibling Age Name of Sibling Age

8. Have any of your brothers and/or sisters died? No Yes

If yes, how old were you at the time of their death? _________

9. Did either of your parents abuse substances? No Yes

10. Have either of your parents been in recovery? No Yes

11. Were the adults in your home abusive to each other? No Yes

12. Did you experience any major trauma before the age of 16? No Yes

If yes, please explain: _________________________________________________

13. Has any member of your family ever been arrested? No Yes

14. Have you ever been in trouble with the law? No Yes

If yes, what for: ___________________________________ Date: __________

15. Are you presently on parole or probation? No Yes

III. Education, Employment, and Military History

1. Number of years of education completed: _________________

2. Degree or certifications achieved: _____________________

3. Did you have a disability as a child? No Yes



4. Have you served in the military? No Yes

If yes, were you deployed? No Yes

5. Has a close family member served in the military? No Yes

If yes, what was the relationship? __________________

Was he/she deployed? No Yes

6. How long have you been employed in your present job? Years_____ / Months_____

7. If you are not currently working, how long have you been unemployed?

Years_____ / Months_____

8. What is the longest you have worked at one job? Years______ / Months_______

9. What types of jobs have you usually done? _________________________________

10. If employed now, what is your present type of work? __________________________

11. Please list your interests and hobbies:

12. What is your spiritual affiliation? __________________________________________

IV. Counseling History

1. Have you ever been in counseling before? No Yes

If yes, where and with whom? ___________________________________________

2. How helpful was it? (Please select one)

Positive Somewhat positive Neutral Somewhat negative Negative

3. Have you ever been diagnosed with a mental illness? No Yes Year ______

If yes, please explain:



Who gave you this/these diagnosis/es?

4. Have you ever been hospitalized for a mental illness?

No Yes If yes, when? Year: _______

5. Has a family member been diagnosed with a mental illness?

No Yes If yes, when? Year: _______

6. What are your goals for counseling? (This question must be answered in order toprocess your application)

7. In order of importance, please rank your top 5 issues, #1 being the most important.

Depression Anxiety Sleep Health Eating Job/career/education Substance use/abuse Family Partner Parenting Abuse/ trauma Emotional support Rapid mood swings Need someone to talk to

Transition into adulthood Life transitions Creating a good life Managing daily stress Loneliness Gender identity Spirituality Grief/Loss Suicidal thoughts Meaning Aging Anger management Other:

Is there anything we didn’t ask you about that you would like us to know?

Counseling Dept Forms\OQ-45 Microsoft Word Conversion 1-10-03.doc - 15 -

OQ - 45.1 Michael Lambert, Ph.D. and Gary Burlingame, Ph.D.

Your Name: Today’s Date:

Instructions: Looking back over the last week, including today, help us understand how you have been feeling. Read each item and circle the number that best describes your current situation.

Never Rarely Sometimes Frequently Almost Always

1. I get along well with others. 0 1 2 3 4 2. I tire quickly. 0 1 2 3 4 3. I feel no interest in things. 0 1 2 3 4 4. I feel stressed by demands of my daily life. 0 1 2 3 4 5. I blame myself for things. 0 1 2 3 4 6. I feel irritated. 0 1 2 3 4 7. I feel unhappy in my marriage

(If not married, mark “0") 0 1 2 3 4

8. I have thoughts of ending my life. 0 1 2 3 4 9. I feel weak. 0 1 2 3 4 10. I feel fearful. 0 1 2 3 4 11. After heavy drinking I need a drink the next morningto get going. (If you do not drink, mark “0")

0 1 2 3 4

12. I find my daily life satisfying. 0 1 2 3 4 13. I am a happy person. 0 1 2 3 4 14. I work/study too much. 0 1 2 3 4 15. I feel worthless. 0 1 2 3 4 16. I am concerned about family troubles. 0 1 2 3 4 17. I have an unfulfilling sex life. 0 1 2 3 4 18. I feel lonely. 0 1 2 3 4 19. I have frequent arguments. 0 1 2 3 4 20. I feel loved and wanted. 0 1 2 3 4 21. I enjoy my spare time. 0 1 2 3 4 22. I have difficulty concentrating. 0 1 2 3 4 23. I feel hopeless about the future. 0 1 2 3 4 24. I like myself. 0 1 2 3 4 25. I am not able to keep disturbing thoughts out of mymind.

0 1 2 3 4 26. I feel annoyed by people who criticize my drinking(or drug use).

0 1 2 3 4 27. I have an upset stomach. 0 1 2 3 4

Counseling Dept Forms\OQ-45 Microsoft Word Conversion 1-10-03.doc - 16 -

Never Rarely Sometimes Frequently Almost Always

28. I am not working/studying as well as I used to. 0 1 2 3 4 29. My heart pounds too much. 0 1 2 3 4 30. I have trouble getting along with friends and closeacquaintances.

0 1 2 3 4 31. I am satisfied with my life. 0 1 2 3 4 32. I have trouble in my daily life because of drinking ordrug use. (If not applicable, mark “0")

0 1 2 3 4 33. I feel that something bad is going to happen. 0 1 2 3 4 34. I have sore muscles. 0 1 2 3 4 35. I feel afraid of open spaces or of driving or being onbuses, subways, etc.

0 1 2 3 4 36. I feel nervous. 0 1 2 3 4 37. I feel my love relationships are full and complete. 0 1 2 3 4 38. I feel that I am not doing well at work/school/home. 0 1 2 3 4 39. I have too many disagreements with other people. 0 1 2 3 4 40. I feel something is wrong with my mind. 0 1 2 3 4 41. I have trouble falling asleep or staying asleep. 0 1 2 3 4 42. I feel blue. 0 1 2 3 4 43. I am satisfied with my relationships with others. 0 1 2 3 4 44. I feel angry enough to do something I might regret. 0 1 2 3 4 45. I have headaches. 0 1 2 3 4

Other Comments (optional):

CLIENT COPY – PLEASE KEEP!

Informed Consent Professional Disclosure Statement

Mental Health Counseling.

Due to the Coronavirus pandemic, William Temple House is providing tele-health sessions to our mental health counseling clients. All sessions will be conducted by phone or by video connection. By signing this form, you consent to this form of service delivery. The following protocols will be operative until normal operations can be reinstated. We will be adhering to the following protocols for online contact.

Recommended Practices for Temporary Distance Counseling:

Clients can receive one session for 50 minutes on a weekly basis.

● At the beginning of each session, we will ask you if you have privacy in your current location; if not, we willrequest you move to a private location to receive counseling.

● We may use a method to ensure that we are actually talking to you, our client, such as a code word orpassword known only to you and the counselor, to indicate that you are talking to your counselor and that it is safe to talk.

● The counselor will obtain and document contact information for emergency referral resources that areavailable in the area where you are located. We may ask for an emergency contact for you in case of a mental health emergency.

● Elicit from you and your counselor ways to limit the potential for breaches of confidentiality that can occur inyour home, e.g., family members overhearing discussion or entering the room.

● Lastly, we may ask for an alternate means of contact to reach you (i.e., phone, email), in case your digitalconnection does not work well and establish a plan to resume contact, e.g., how many attempts, by what method(s). I. How to make counseling effective:

A. Research shows that most people benefit from counseling. Individuals and couples in counseling may not always achieve his or her wanted outcome. At times counseling may be difficult. In order to increase the chances of counseling being successful the following are recommended:

B. Receive counseling on a regular basis.

C. Medication may be needed before counseling can be effective. You will need to work with your medical provider if that is the case.

D. Please do not arrive at a session while under the influence of alcohol, marijuana and/or other drugs. In cases where you need support for abstinence your counselor may ask you to participate in a 12-Step program or Smart Recovery. Both programs offer online meetings through Zoom and teleconferencing.

II. Confidentiality. Counseling is confidential. Material about you and your counseling will be kept confidentialin all situations with the exception of harm to self and others. Oregon law requires that we report:

Child abuse, elder abuse, or abuse of the mentally ill or cognitively challenged. Under Oregon law child abuse includes physical abuse, neglect, sexual abuse and sexual exploitation including the exposure of children to graphic sexual material such as pornography. Child pornography must be reported by law.

F. Domestic violence that occurs in front of children is a felony and will be reported.

G. Suicide and other forms of serious self-harm will be dealt with to protect the client. If hospitalization is required to ensure safety, steps will be taken towards that end.

H. In cases where the client threatens physical and/or sexual harm to another individual, the individual and the proper authorities will be notified.

I. By signing this form, you give permission to your counselor to consult. Most of our counseling is done by graduate student interns or post-graduate Counseling Residents. They are closely supervised and meet certain requirements before being allowed to practice. They will be sharing information within individual and group supervisors. Your name will not be used with off-site supervisors.

J. Couples and Families: Adhering to the accepted standard of the professional counseling community, one single file is kept for each couple and family in counseling. The William Temple House Counseling Department may be limited in its ability to protect the individual privacy of those named in couples and family case notes, if requested by a judge’s subpoena.

III. General Information

A. If you run into your counselor outside of William Temple House, for the sake of confidentiality and privacy, your counselor will not acknowledge you. Please do not see that as a personal rejection but as a protection of you. Counselors are not allowed to e-mail or participate in any social media sites with their clients, such as Facebook, even after counseling has ended.

B. Counselors are not allowed to initiate or receive hugs or other forms of touching with clients.

C. Counselors are not allowed to receive gifts from their clients.

D. Counselors are not allowed to meet with you off-site, attend events that involve you, or visit you if hospitalized.

E. All client chart notes have been prepared solely for use by William Temple House (WTH) personnel and its non-licensed Counseling Interns as part WTH’s educational, licensure, and/or professional training protocols.

F. The Chart Note:

a. Is the property of WTH.

b. Contains no mental health diagnoses.

c. Is not intended for use by any WTH client or third party in any civil, criminal, or administrativeproceeding of any kind.

d. Is intended to be used solely by WTH as part of its normal and usual educational and trainingprotocols.

e. Shall not be used by any WTH clients or third parties for any purposes other than their mentaland/or medical health and well-being, except as otherwise required by statute, administrativeregulation, or lawful court order.

f. These limitations have been fully explained to the client and he/she/they has/have consentedto them.

g. William Temple House provides counseling; we do not perform psychological or psychiatricevaluations for any purpose. We do not provide case notes and other records to GeneralAssistance, Social Security, Children and Family Services, for divorce and/or child custody, orfor any other legal issue. We will not give clients copies of their records. By signing this form,you waive your right to use our records in any matter of disability or legal process. However,under conditions of a bench subpoena we must release records.

G. If you are unable to make your appointment, please call and cancel ahead of time. If you fail to come to three appointments without canceling, your case will be closed.

H. When your counselor initially makes contact by phone, write down their name and phone extension number. If you need to contact your counselor, you need to know your counselor’s name.

I. In case of a mental health emergency call William Temple House during business hours. We will make every attempt to contact your counselor and have them contact you. After business hours call 911 or the Multnomah County Crisis Line (503.988.4888) or go to your nearest hospital emergency room.

If any problem should arise you can talk to your counselor’s supervisor at any time. Issues can also be discussed with the Clinical Director at 503-226-3021 (x1220). [do you want to include Dr. Bettis’ name so they know who the Clinical Director is?]

William Temple House reserves the right to deny counseling services.

KEEP THIS COPY FOR YOUR RECORDS – THANK YOU

Confidential Adult Individual & Couples Application ... · Individuals and couples in counseling...

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