PATIENT INTAKE (PART FOUR)
Thank you for taking the time to complete this information. Your intake will include four parts.
PART ONE: collecting general information about you and financial information for billing purposes
PART TWO: gathering biopsychosocial information (e.g., ranging from how you’re feeling today to habits and history)
PART THREE: reviewing Kizaur Counseling privacy practices
PART FOUR: consenting to being treated by Kizaur Counseling
After you complete each part of your intake and click the "SUBMIT" button, you will then be taken to the next part.
All the information you share during this process remains completely confidential and helps me better help you.
CONSENT TO RECEIVE TREATMENT
I understand the risks, approximate length of treatment and the possible consequences of deciding on counseling which may include the following methods and interventions: stabilization, decrease and relief of symptoms, improved coping strategies, problem-solving and use of resources, skill development, stress management, behavior modification, cognitive restructuring, and wellness interventions.
While I expect benefits from counseling, I fully understand and accept that because of factors beyond the counselor’s control, such benefits and desired outcomes cannot be guaranteed. I understand that regular attendance will produce the maximum possible benefits but that I am free to discontinue counseling at any time. I understand that cancellation with less than 24-Hour Notice may result in a cancellation fee of $75*. *I reserve the right to charge less based on given circumstances.
I give permission to Matthew Kizaur MA, LPC, MEd, LPSC to conduct counseling sessions over the phone or through video counseling. In the event that I choose to facilitate my counseling in this manner, I am responsible for finding a confidential location free from interruption during the course of the session. I understand that the utilization of online services and/or the telephone may limit confidentiality.
I understand that I am responsible for showing up to my telephone or video appointment on the day and time for which it is scheduled. If I fail to show up for my appointment, I might be charged a session fee, just as a failure to show up for an office appointment.
In keeping with the ethical standards of the American Counseling Association and state and federal law, all services are kept confidential except as noted below and in the accompanying Notice for Privacy Practices.
- If a client is likely to harm himself or others (suicidal and homicidal ideation/plan).
- When there is reasonable suspicion of abuse of children, elderly, or disabled persons.
- When there is a valid court order to release the information.
- When information is required by the individual’s insurance.
- The client signs a release of information disclosing information to a third party.
- Client information will also be shared with Wendy Nathan, LPCC-S who is supervising Matthew Kizaur, MA LPC, MEd, LPSC. Wendy Nathan, LPCC-S is bound to the same confidentiality standards.
As part of the ACA Code of Ethics (2014), I am to respect the privacy of a client’s social media presence and take precautions when necessary. Therefore, I do not connect, comment, subscribe, or seek information of clients through social media platforms and will not interact with any virtual presence representing a client, family member, or a member of the client’s social network.
If you are unable to reach me and are experiencing a crisis, contact 911 or go to the nearest Emergency Room and ask for the mental health professional on call. If I will be unavailable for an extended amount of time I will provide you with the name of a colleague to contact, if necessary.