In the dropdown menu below please choose the counselor that has been assigned to you.
Please Choose One Roger Bear, MDiv Jim Evans, PhD, MHA Ann Hogue, PhD Elizabeth Sanchez PsyD,MS Stephanie Nelson Mike Rotman MDiv, DMin
READ & SIGN ADULT CONSENT TO PARTICIPATE IN COUNSELING This form is for each person 18 years of age or over that will be counseled.
• I, agree to participate in the counseling services offered through Community Christian Counseling, Inc. and which will be provided by their counselor representative (licensed or Biblically Trained)
• I understand that CCC counselors do not counsel from a any psychological model. Rather, the counseling model, training, education and lives of our counselors are based in biblical principles and encouragement.
• I acknowledge that I have been provided, and have signed a copy of Counselor-Client Services Agreement of Community Christian Counseling.
• I have been provided a copy of the Notice of Privacy Practices.
Sign Consent To Participate In Counseling
VISITOR IN SESSION VISITOR IN SESSION
Use this section for visiting guest of Client.
REGARDING INSURANCE REGARDING INSURANCE
We do not bill insurance for our services. We can provide an insurance-coded receipt for a counselee requesting insurance reimbursement. Some insurance companies will reimburse for faith-based services and some will not.
COUNSELOR – CLIENT SERVICES AGREEMENT
READ & SIGN COUNSELOR – CLIENT SERVICES AGREEMENT Welcome to our Biblically-based counseling services. This Counselor-Client Services Agreement (hereinafter, Agreement) contains important information about our counseling services and business policies. It also contains information about the Federal Health Insurance Portability Act (HIPPA). HIPPA provides privacy protections and client rights concerning your counseling information. HIPPA also requires that we provide you with our Notice of Privacy Policies and Practices , regarding your counseling, payment and our healthcare operations.
Counseling Services
Participating in counseling can have benefits and risks. That is, counseling often involves discussing difficult aspects of your life. You may experience many different emotions during the counseling sessions or even after you leave the center. On the other hand, counseling has repeatedly been shown to have many mental, emotional, physical and even spiritual benefit. Counseling often leads to better relationships, solutions to even long-standing problems, and reduction in feelings of depression and/or anxiety. Community Christian Counseling (hereinafter called CCC) makes no promises, guarantees or predictions about how you will respond to our counseling services.
Emergency Situations
If a situation (such as life-threatening emergency) arises in your life that you feel cannot wait until your regularly scheduled appointment, you have two options: 1) call the CCC office (812-244-0400) and speak to the Receptionist or leave a message on the recorder. Or 2) go to the nearest Hospital Emergency Room. Note that cell phone conversations cannot be guaranteed as confidential, due to limits of cell phone security.
Limits of Confidentiality
The law protects the privacy of all communication between a client and their counselor. In most situations we can release information about your case to others, only if you give us written permission to do so. Our NOTICE OF PRIVACY POLICIES & PRACTICES , which you have been provided, discuss that in full, plus it describes the exceptions to confidentiality of your information that may be necessary. Very briefly, the circumstances that would require us to release your information without your permission include: requirements by local, state or federal law enforcement authorities, cases involving abuse or neglect, to military authorities involving members or veterans of the U.S. Armed Forces, Worker’s Compensation issues, various health oversite activities, and applicable lawsuits or disputes. Again, all of these are discussed in our NOTICE OF PRIVACY POLICIES & PRACTICES, which you have received.
Situations in which we are legally obligated to take action
If a CCC counselor and leadership believes it is necessary to protect others from harm, information about your counseling may be released without your permission to legal authorities or protective agencies as required by law. Those situations include: 1) If we have reason to believe that a child is a victim of abuse or neglect. 2) If we have reason to believe that someone is an endangered adult. 3) If a client communicates an actual threat of violence against an identifiable victim, or describes the type of violence or means to do harm to others. 4) If a client communicates an imminent threat of physical harm to him/herself. If these or similar such situations arise in your case, we will make every reasonable effort to fully discuss it with you before taking any action, but in some cases notification may not be possible.
Professional Records
We want you to be aware that your counseling chart at CCC has two important section. One section contains the CCC form PERSONAL DATA INVENTORY. This section is tabbed MEDICAL REPORTS in your chart. This section may contain reports or test results provided by a physician, laboratory, another counselor or therapist, or any other medical records provided to us in the course of your counseling at CCC. A second section in your chart is COUNSELING NOTES. These notes are specifically for the use of your CCC counselor. The notes may include information about your reason(s) for seeking counseling, notes on the conversations in your sessions, how you are, or are not responding, how these issues impact your life, the goals set for your counseling progress, your progress toward these goals, and other information that does not need to be in your MEDICAL REPORT. The COUNSELING NOTES are kept separate from your MEDICAL REPORT. Your COUNSELING NOTES are not available to you and cannot be sent to anyone, without your written, signed authorization.
Client Rights
Federal HIPPA regulations allows for: 1) You to request that we amend your counseling record, 2) For you to request restrictions on what information from your MEDICAL RECORD is disclosed to others, 3) An accounting of most disclosures of your counseling information, to whom it was disclosed, and when, 4) having any complaint you have about our management of your records to be included in your CCC record, and 5) You to have a paper copy of this Agreement.
Minors and Parents
The parents or legal guardian(s) of CCC clients under 18 years of age, who are not emancipated, have the right to examine their child’s counseling record. Under certain difficult cases and situations, we may ask the parents of minors clients to surrender their right to see their minor’s counseling record. If the parent agrees, we will thereafter give the parent only general information about their minor’s sessions. Any other disclosure to the parent will require the minor’s authorization – unless the counselor believes there is an imminent physical danger to the minor or someone else.
Billing and Payments
CCC expects payments for each session at the time the sessions are provided. CCC does not bill third-party payers (insurance companies) for our services. If there is a subsidy arrangement for your counseling, CCC must have the name, address, and prior authorization of the party to be invoiced.
If your CCC account is past due, we reserve the right to forward your account to a collection agency, who will then receive the financial information about the amounts due for your services.
You may be charged up to $30.00 for personal checks given to CCC, but returned by your bank.
Insurance Reimbursement
As stated above, CCC does not bill insurance companies for our services. If you request, we will provide you with an insurance coded receipt for your payment to CCC. It will be your responsibility to submit the coded receipt to your carrier, and communicate with them about any reimbursement.
Your signature on this Counselor – Client Services Agreement , indicates that you have read and understand the information, and agree to abide by its terms during our professional relationship.
General Information
Clients and visitors shall not carry Personal weapons in the office of CCC.
No cameras or any type of recording device (except for cell phones) are permitted in the office. If you have any intention of making photos or recordings with your phone, you must submit a written request to do so to CCC. We are under no obligation to agree to photos or recordings.
Please Sign Counselor Client Services Agreement
PRIVACY POLICIES & PRACTICES This notice describes how your counseling information may be used and disclosed, and how you can get access to this information. PLEASE READ IT CAREFULLY!
Click the link below to read the Notice Of Privacy Policies & Practices. ANOTHER WINDOW WILL OPEN, BUT THIS FORM WILL REMAIN OPEN. JUST RETURN TO THIS TAB ONCE YOU READ THE NOTICE.
PERSONAL DATA INVENTORY
CURRENT ISSUES Main reason(s) for contacting our office:
How long has this been a problem?
Have you Sought counseling for this before? If yes, where, when and with whom?
Do you have family members that have sought counseling or been treated for emotional issues? If yes, briefly explain:
Have you experienced any major loss, trauma, or been the victim of any emotional or physical abuse? If yes, describe:
Please describe your current physical health or issues with your health:
Describe your physical/medical history. If you are currently under the care of a physician, what is the treatment addressing?
Please list any medications you are currently taking:
FAMILY HISTORY List all those living at your address:
MARITAL STATUS If married, what is your spouse’s first name?
If they are employed, what is their occupation
Briefly describe your marital history
Are your biological parents living?
If yes, describe your relationship with them:
MY FAITH JOURNEY If no, what do you believe about life/death?
Why did you seek Christian Counseling?
Briefly describe your prayer life
Do you attend church regularly?
Do you read the Bible regularly?
How would you describe your relationship with the Lord?
SUBSTANCE USE/ABUSE How would you describe your use of alcohol?
Have you ever used illegal drugs?
If yes, which drug(s) and how long ago?
Do you have a family history of drug/alcohol use/abuse?
YOUR EDUCATION Highest level of education completed
MILITARY SERVICE Branch of service & type of discharge?
Are you a combat veteran?
Did you sustain any injuries associated with your service? If yes, what type?
Did you receive any disability associated with the injury?
EMPLOYMENT HISTORY Are you currently employed?
If yes where, and for how long?
What other jobs have you held in the past 3 years?
LEGAL HISTORY Are you currently involved in any legal actions that could influence your counseling? Please describe:
Do you anticipate asking your counselor to testify?
DISABILITIES Have you ever been diagnosed by a medical professional as having a disability?
What special assistance/accommodations do you require, if any?
Who do you designate as an emergency contact? (PLEASE INCLUDE THE DASHES IN YOUR PHONE NUMBER EX. 123-456-7891)
