9432 Katy Freeway, Suite 450, Houston, TX 77055

Phone: 281-450-3717

Email: Laura@LauraDavisonCounseling.com

CLINICAL INTERVIEW INTAKE FORM

List all medical and mental health conditions for which you are currently being treated.

I, the undersigned, agree to engage in the process on hypnosis. I understand that I will have all choices at all times and can start and end the process at any time, even during my session. The services rendered to me are defined as the learning of self-hypnosis to induce positive thinking, create commitment to change and to learn the techniques of self-hypnosis to produce self-control over physical experiences and emotional awareness.

I understand the services provided do not represent any medical treatment, nor are these services meant to replace medical treatment which may be prescribed by a physician.

I agree to continue medication as prescribed by my attending physician(s) and understand that hypnotherapy is not a substitute for medical care. If any medical symptoms progress or become acute I will seek medical attention from a licensed healthcare provider. In the event of a medical emergency or if I feel suicidal, I will call 911 or other emergency help. I understand that the methods of hypnosis include relaxation, breath work, creative visualization, positive affirmation, self-awareness development and other techniques and may produce physical and emotional responses. I agree to inform my hypnotist of any adverse feelings or experiences related to this process at the time of my awareness of them. I have been informed as to the limits of the effectiveness of hypnosis.

As a client, I have read, understood, and agree to the terms and conditions of the information presented in this form.

Please type your full name below, then sign, print and date below to indicate that you understand what you have read.

1.) I, the undersigned, accept financial responsibility for payment of all fees at the time of visit, unless other arrangements have been made with Laura Davison Counseling.

This form provides information about our counseling relationship, procedures involved, and your authorized consent to treatment.

Cancellations: Please understand your scheduled appointment is time that is saved specifically for you and your treatment. Appointment reminders are sent out in advance with the opportunity for you to modify your saved time with Laura, but still allows us to offer that time to other clients. We understand that life is very fluid and dynamic, and things come up unexpectedly. However, appointments canceled within 24 hours of your saved time will be assessed at $75 and appointments that are broken ("no show") will be charged at the full rate of $150.

Fee Structure: The client is financially responsible for payment of fees, which will be collected at the time of service. In the event of an accrued balance, the client and therapist can negotiate a payment schedule.

As a client, I have read, understood, and agree to the terms and conditions of the information presented in this form.

I authorize Laura Davison Counseling to keep my signature on file and to charge my Credit Card listed below.

I understand that this form is valid for the duration of my treatment unless I cancel the authorization through written notice to the service provider.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal information.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care options.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement of activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

•  The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

Client Rights/Confidentiality services will be rendered in a professional manner consistent with accepted legal and ethical standards. Information about you that is obtained during counseling sessions will not be revealed to anyone else without your consent except where disclosure is required by law. These instances include:

• Where there is reasonable suspicion of physical/sexual abuse to children or elderly persons
• Where you present a serious danger to yourself or others
• Where a court orders the counselor to disclose information
• If at any time for any reason you are dissatisfied with our services, please let us know. We also reserve the right for consultation with other professionals whenever believed necessary.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. 

This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPAA or to file a complaint:

US Dept. of Health & Human Services

200 Independence Avenue, SW

Washington, DC 20201

Toll Free: 1-877-696-6775

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certification.

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.