1745 S Alma School Rd., Suite 230, Mesa, AZ 85210 | Phone: 480-668-8301 | FAX 480-558-3020 | familystrategies.org
NEW CLIENT INFORMATION
(please print clearly)
Revised 3.1.22
CLIENT INFORMATION
Client Name: ___________________________________________________________ DOB:____________________________ Age: _____
Last MM/DD/YYYY
First
Client Address: ________________________________________________________________________________________________
City State Zip
Cell Phone: ____________________________________________ Home Phone: _______________________________________________
Which number do you prefer we use to contact you? Cell Home
Email Address: __________________________________________________________________________________________________
Yes, I would like to receive periodic emails about Family Strategies’ specialty programs and services. We DO NOT sell or provide
email addresses to others.
Gender: Male Female Other (please clarify) _____________________________________________________________________
Employer: ________________________________________________ Occupation: _____________________________________________
Relationship Status:
Single Married Separated Divorced Widow/Widower Long-term relationship
To whom do you authorize Family Strategies to speak with regarding your scheduled appointments? ________________________________
To whom do you authorize Family Strategies to speak with regarding your account/financial matters? ________________________________
Their relationship to you: ____________________________ Your signature: _________________________________________________
EMERGENCY CONTACT
Contact Name: _________________________________________________________ Phone: ___________________________________
First Last
Relationship to you/client:_______________________________________________________________________________________
EXCHANGE of CONFIDENTIAL INFORMATION
In efforts to provide me with the best possible care, I hereby authorize my therapist to share confidential information regarding my treatment with
other professional staff at Family Strategies. Permitted disclosures include, but are not limited to, discussion and sharing and/or providing access to
my records as appropriate, which includes, but is not limited to, treatment plans, intake assessments and progress notes. “Professional staff” includes,
but are not limited to, the Executive Team, Clinical Supervisors, therapists and interns who have expertise regarding specific clinical issues and
treatment planning. I give this authorization of my own free will and have discussed any questions or concerns with my therapist. By signing this
consent to exchange confidential information, I acknowledge that I have both read, understood and that I agree to all the terms of this release. I
understand that my records are protected under Federal and State Confidentiality Regulations. I understand that I may revoke my consent at any time
by written notice, and that my participation in Family Strategies’ treatment program(s) is conditional on the above consent.
Signature of Client or Legal Guardian if client is under the age of 18 Date
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FOR MINOR CHILD ONLY
NOTE: If parents are divorced, court custody documents must be provided prior to the first session. If parents share joint custody, both
must sign the “Client Consent” form.
Parent/Legal Guardian/Father Name/Phone/Email:______________________________________________________________________
Parent/Legal Guardian/Mother Name/Phone/Email:_____________________________________________________________________
Current school: _________________________________________________________ Grade: __________________________________
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FOR CLIENTS WITH BCBS COVERAGE ONLY
*DO NOT fill out this form unless you have BCBS coverage.
We can submit claims to BCBS only for payment.
If your insurance carrier is not currently one with whom we contract, your account will be considered “Self Pay”
and will be billed accordingly. If requested, a super bill can be provided that you can submit to your insurance
company for reimbursement for any out-of-network benefits you may have.
CLIENT INFORMATION
In addition to providing this information we will need to scan your insurance card and drivers license.
Client Name (as appears on your insurance card): ________________________________________________________________________
Client Date of Birth: _____________________________ Gender: Male Female Other: _________________________________
MM/DD/YYYY please clarify
Plan Administrator: ____________________________________________________________________________________________
as shown on card. Example: AZBLUE, Meritain, AnthemBCBS, etc.
Member ID __________________________________________________________________________________________________
include all letters and numbers
PPO Group #:____________________________________________ Other Group #: __________________________________________
usually consists of letters and numbers for some third-party administrator plans
Employer: ___________________________________________________________________________________________________
PRIMARY INSURED INFORMATION
CHECK THIS BOX IF THE CLIENT AND SUBSCRIBER ARE THE SAME PERSON. (skip to Financial Responsibility)
Subscribers Name (as appears on your insurance card): ___________________________________________________________________
Subscriber Date of Birth: ____________________________ Gender: Male Female Other: _______________________________
MM/DD/YYYY please clarify
Relationship to Client: __________________________________________________________________________________________
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Is BlueCross BlueShield your primary insurance? Yes No
FINANCIAL RESPONSIBILITY
Client Name: ___________________________________________________________________________________________________________
Name: _________________________________________________________ Relationship: ___________________ DOB:_ ___________________
Address: ___________________________________________________________________________________________________
City State Zip
Cell Phone: ______________________________________________ Home Phone: ___________________________________________________
Email Address: _____________________________________________________________________________________________________
I accept full responsibility for all fees due for professional services. I realize that any third party billing is out of courtesy to me and does not transfer
any financial responsibility for unpaid services. I understand that I will be billed for all charges until a third party authorization is signed by the third
party payor and on file with Family Strategies.
If I have Blue Cross Blue Shield Insurance, I understand that I am responsible for any allowable amount that BCBS does not cover.
If you as the client are an adult and a family member or friend is providing payment on your behalf, do you authorize Family Strategies to speak with
them regarding the financial aspect of your account? Yes No
Signature of Responsible Party (Required) Date
AUTHORIZATION for DEBIT/CREDIT CARD CHARGES
By my signature below, I authorize FAMILY STRATEGIES COUNSELING CENTER (Floyd Godfrey, LPC) to debit/charge the account number I
have specified below:
At the time of check-in
The day of my telehealth appointment
For missed (No Show) appointments
For late cancelations. (Late cancelations are defined as up to 24 hours prior to my appointment.)
Having a card on file to use for your sessions is required and will enable us to expedite your check in time and reduce overhead allowing us to keep
fees as low as possible.
CHECK ONE BOX: USE FOR ALL SESSIONS USE FOR NO SHOWS OR LATE CANCELATIONS ONLY
CHECK ONE BOX: YES NO May we PRE-CHARGE your card when you are scheduled at a time when no receptionist is available at the
front desk (i.e. Saturdays, late, or early hours). Usually within 1 business day of your scheduled appointment.
GROUP THERAPY: If you join a group, this credit card will be charged for group fees as well unless you notify us otherwise.
ONE WEEK’S WRITTEN NOTICE IS REQUIRED TO CANCEL THIS AUTHORIZATION
CREDIT CARD INFORMATION
Please check box: VISA MasterCard Discover Card Amex
Name as it appears on the card: __________________________________________________________________________________
Credit Card #: ________________________________________________________________________________________________
Expiration Date: _______________________ CVV#:_________________ Billing Zip Code:______________________________
IS THIS AN HSA/FSA CARD? Yes No
Cardholder Signature Date
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ADDITIONAL CLIENT INFORMATION
Therapist you are scheduled to see: _____________________________________________________________________________________
How did you hear about Family Strategies:
Family Member Friend Church Insurance website Google search Psychology Today
Social Media Other _____________________________________________________________________________________________
For what reason are you seeking counseling today? ____________________________________________________________________
____________________________________________________________________________________________________________
BEHAVIORAL HEALTH HISTORY
Yes No Do you have a history of depression?
Yes No Have you ever taken medication for depression?
Yes No Does any member of your family have a history of depression?
Yes No Does any member of your family have a history of mental illness?
Yes No Have you previously received help through counseling?
If yes, who was your therapist? _______________________________________________________________________________
Yes No Are you currently working with another therapist?
If yes, what is this therapist’s name? ___________________________________________________________________________
Do you authorize Family Strategies to communicate with this therapist? Yes No. I do NOT authorize
Client signature:________________________________________________________________________________________________
OVERVIEW OF MEDICAL HISTORY
Yes No Do you have a Primary Care Physician?
PCP Name: ______________________________________________________________ Phone: __________________________________
What is the date of your last physical exam? ___________________________________________________________________________
Do you authorize Family Strategies to communicate with your PCP? Yes No. I do NOT authorize
Client signature: ___________________________________________________________________________________________________
Please list any hospitalizations in the last year: ___________________________________________________________________________
Have you had, or do you currently have, any symptoms or problems in any of the following areas to a significant degree:
Chest/heart Head/Brain Injury Neck Intestinal Kidneys
Lungs/Respiratory Ear/Nose/Throat Back Skin Reproductive
Bladder Bowel Other: ____________________________________________________________
Please, briefly describe your symptoms: _________________________________________________________________________________
Have you had, or do you currently have, any medical conditions or diseases? Please list: __________________________________________
_________________________________________________________________________________________________________________
Please list the medical conditions your parents, grandparents or siblings have had or currently have and indicate which family member:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Please list any medications you currently take and the condition for which you take them:
Medication: _______________________________________________ Taken for: ______________________________________________
Medication: _______________________________________________ Taken for: ______________________________________________
Medication: _______________________________________________ Taken for: ______________________________________________
Medication: _______________________________________________ Taken for: ______________________________________________
Medication: _______________________________________________ Taken for: ______________________________________________
Please list any medications you are allergic to: ____________________________________________________________________________
Do you currently have an infectious disease? Yes No
This is a self-report – Please note any that apply:
Strep Lice HIV STD Chicken Pox Measles, Mumps, Rubella Bed Bugs
Other (please list): _______________________________________________________________________________________________
Do you have a learning disability?
ADHD APD Dyscalculia Dyspraxia Dysgraphia Dyslexia LPD Memory
Language Processing Disorder Non-Verbal Learning Visual Perception/Visual Motor Deficit
Other (please list): ____________________________________________________________________________________________
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HEALTH HABITS
Yes No Do you drink alcohol? If yes, how much alcohol? ___________________________________________/day/week/month
Yes No Do you vape/smoke cigarettes? If yes, how often and how long? ______________________/day ______________ # years
Yes No Do you have a history of substance abuse?
Yes No Are you addicted to or abuse legal or illegal drugs?
Yes No Do you drink caffeinated beverages? If yes, how much and how often? ____________________________________/day
Yes No Do you have problems with eating or your appetite?
Yes No Do you exercise regularly?
Yes No Do you feel comfortable with your weight?
Yes No Do you have trouble sleeping?
Yes No Have you ever had a seizure?
Yes No Do you have a history of head injuries or concussions? If yes, when ___________________________________________
CHILD/ADOLESCENT HEALTH HISTORY (only if client is under the age of 18)
Who lives in the home? (name, age, relationship to client) __________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Yes No Are there pets in the home? If yes, what type? ________________________________________________________
PRENATAL HISTORY (biological mother of minor client listed on page 1):
During Pregnancy
Yes No Medical Conditions Describe: ___________________________________________________________________
Yes No Emotionally Stressful Describe: ___________________________________________________________________
Yes No Tobacco/Cigarette Use Describe: ___________________________________________________________________
Yes No Alcohol Use Describe: ___________________________________________________________________
Yes No Substance/Drug Abuse Describe: ___________________________________________________________________
Birth
Yes No Premature Describe: ___________________________________________________________________
Yes No Full Term Describe: ___________________________________________________________________
Yes No Vaginal Delivery Describe: ___________________________________________________________________
Yes No C-Section Describe: ___________________________________________________________________
Yes No Birth Weight Issues Describe: ___________________________________________________________________
Yes No Birth Injury Describe: ___________________________________________________________________
Yes No Oxygen after Delivery Describe: ___________________________________________________________________
Yes No Admit to NICU Describe: ___________________________________________________________________
Yes No Infection Describe: ___________________________________________________________________
Yes No Jaundice Describe: ___________________________________________________________________
Yes No Seizures Describe: ___________________________________________________________________
Yes No Birth Defects Describe: ___________________________________________________________________
Yes No Feeding Problems Describe: ___________________________________________________________________
Yes No Postpartum Depression Describe: ___________________________________________________________________
Yes No Other Describe: _________________________________________________________________
To reschedule or cancel an appointment, please call our Client Care Specialists at 480-668-8301, x 1001.
To reach our Billing Department, including questions about insurance, please call 480-668-8301, x 1300.
To reach the Office Manager, please call 480-668-8301, x 1002.
We look forward to serving your behavioral health needs.
If you need immediate or emergency mental health care, please call the Behavioral Health Crisis Line at 602-222-9444.
THIS NUMBER IS NOT ASSOCIATED WITH FAMILY STRATEGIES COUNSELING CENTER.
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CLIENT INFORMATION and INFORMED CONSENT
Please read ALL information carefully and thoroughly and initial where indicated. Revised
8.26.21
NOTE: If you are seeing a therapist at Family Strategies for couple’s therapy, each person must fill out a separate set of forms for
your first couple’s session.
WELCOME
It takes courage to reach out for support and we look forward to supporting your healing journey. These forms contain information
about Family Strategies’ professional counseling services and business policies. It is important that you review the following
information before beginning your first session. Please feel free to ask any questions you may have about these policies; we are happy
to discuss them with you. There are multiple places where your signature will be required on the following forms.
THERAPY SERVICES - RISKS and BENEFITS
_____ (initial) The role of a licensed counselor is to assist you with challenges that may impact you emotionally. Counseling often
involves discussing difficult aspects of your life. During our work together you may experience uncomfortable feelings such as
sadness, guilt, shame, anger, or frustration. As a result of what comes out of your therapeutic work and the decisions you make,
important relationships may be impacted or may end. Your journey in therapy may also lead to healthier relationships. If you ever have
concerns about your therapy process, I encourage you to discuss this with your therapist during your sessions so that we can
collaborate together as you move forward.
TERMINATION of THERAPY
_____ (initial) You may terminate therapy at any point. When our work comes to an end, we ask that you schedule at least one final
session in order to review the work you have done. Occasionally clients return to therapy to process new challenges. If you decide to
return in the future, please know that we have an open-door policy and we welcome the possibility of working together again.
However, it will be at our clinical discretion and also dependent on your therapist’s availability. There can be a wait of up to 2-4
weeks. If your therapist is unable to see you immediately,
we will be happy to add you to the waiting list, or provide you with a
referral to another competent therapist(s).
Your therapy records are closely protected and maintained for six (6) years after the last date of treatment. If you would like to obtain a
copy of your treatment records, you can do so by sending a written request directly to your therapist at our office.
LENGTH of THERAPY
_____ (initial) Therapy is a process that is unique to each client and the challenges they are experiencing. Some issues can be worked
on very effectively in a short period of time, and other challenges may take much longer. It can be difficult to predict exactly how long
therapy will last so this is best discussed in your first session. You and your therapist will put together a treatment plan and goals that
you will be working toward. If you have questions regarding the length of treatment, please feel free to discuss this with your therapist
at the start and/or at any point during therapy.
DUAL THERAPY
_____ (initial) It is unhelpful for two different therapists to provide counseling for the same client at the same time. Unless there is a
compelling clinical reason, a crisis, or a specialized therapy treatment plan that we will be working on, we do not work with clients
who are under the care of another therapist outside of Family Strategies. If you are working with another therapist outside our office,
please disclose this so that you can discuss next steps with your Family Strategies therapist. If your therapist has referred you to
Family Strategies for specialized treatment (i.e. sex addction, sex therapy, etc.), we will need to have a release on file from you in
order to coordinate care with your primary therapist and collaborate on a clinical plan that best supports your process.
CONJOINT SESSIONS
_____ (initial) On occasion, and only if it benefits the client’s therapy goals, your therapist may invite you to ask a family member or
significant other to join you for a therapy session. It is important to note that this is done only on occasion and at your therapist’s
clinical discretion when it best serves the client. If the person joining the session is your significant other,
this does not constitute as
couple’s therapy, rather it is as a support to your work, and/or a check-in session. Additionally, the third party (friend or significant
other) is not joining the session for his or her own therapy, nor will your therapist work with them as a therapist.
NO SECRETS POLICY
_____ (initial) Please note that with couples therapy the couple is the client (e.g. the treatment unit), not the individuals. As such we
practice a “no secrets” policy when conducting marital/couples’ therapy. This means that confidentiality does not apply between the
couple when one member of the treatment unit requests an individual session or contacts the couple’s therapist outside of the therapy
session to share a secret. Secrets do not include personal thoughts, feelings, desires, etc. of one of the parties, rather information that
would be painful, harmful, or betraying to the other partner (i.e. affairs, financial betrayal, etc.). On occasion an individual session
may be scheduled to assist in the overall therapy process to the treatment unit (e.g. the couple) and will be scheduled only when
mutually agreed upon. Please understand that the majority of information shared in the individual sessions will not be held in
confidence or secret in the couple's sessions. Your therapist will encourage the person holding the secret to share the secret in the
following session and will support the client in doing so. Your therapist also reserves the right to share or disclose information
revealed by one partner in an individual session to the other partner or family members as deemed appropriate or necessary to support
the treatment unit’s overall treatment progress and goals.
SOBRIETY POLICY
_____ (initial) Family Strategies asks that all clients, couples, families, and group members arrive at therapy sober and not under the
influence of drugs and/or alcohol. If any member of our staff notices that you are intoxicated or substance impaired, the therapy
session will be immediately terminated. Once you are safely home, you may reschedule the therapy session. You will be charged your
full fee for the session if you arrive intoxicated or impaired.
PHYSICAL CONTACT
_____ (initial) Sexual contact is never acceptable in the therapeutic relationship. In some cultures, a supportive hug or other physical
contact can be an expression of affection, or a greeting, or a goodbye. However, supportive physical contact can also be misconstrued,
triggering, or may interfere with the therapeutic relationship. As a general policy our therapists do not offer supportive physical
contact of any kind within the therapeutic relationship. Please understand, this is not an expression of judgment, dislike or dismissal,
rather it is in the best interest of your clinical care based on a professional and therapeutic boundary. You always have the right to
refuse physical contact at any time or for any reason.
CONFIDENTIALITY
_____ (initial) Therapy is best experienced in an atmosphere of trust. Thus, all therapy services are strictly confidential and may not
be revealed to anyone without your written permission. There are exceptions to confidentiality where disclosure is required by law
(see below). Your confidentiality is very important to us. Should you request that your therapist speak with another professional or
person (i.e. doctors, former therapists, teachers, family, friends or anyone else outside the therapy room), you must first provide your
signed written consent in order to do so and only after your therapist determines if this is in the best interest of supporting your
therapeutic process and progress. There are times when consulting with adjunct clinicians can be very helpful in providing you with
the best possible care. As a member of the therapeutic team at Family Strategies, your therapist has a unique opportunity to utilize the
vast experience and expertise of other clinicians.
In an effort to provide me with the best possible care, I hereby authorize my therapist to exchange confidential information regarding
my treatment to other professional clinical staff at Family Strategies, LLC. Professional staff includes, but are not limited to, the
Executive Directors, Clinical Supervisors, and other therapists who have expertise regarding specific clinical issues and treatment
planning. I give this authorization of my own free will and have discussed any questions or concerns with my therapist. By signing
this consent to exchange confidential information, I acknowledge that I have both read, understood and that I agree to all the terms of
this release. I understand that my records are protected under Federal and State Confidentiality Regulations.
Client’s Signature Date
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LEGAL EXCEPTIONS to CONFIDENTIALITY
_____ (initial) Your information is always confidential with the exception of information relating to child abuse, suspected child
abuse, elder abuse, dependent adult abuse, or intent to harm self or others, or unless mandated by a court of law. Legally, therapists are
mandated reporters of abuse or intent to harm another. If you are suicidal or homicidal your therapist at Family Strategies will take all
reasonable steps to prevent harm to you or another.
A minor is defined as any person who is legally under the age of 18. Wether your therapist works with minors or not, they are
mandated reporters of any sexual acts involving minors. This means that if any therapist or staff at Family Strategies learns of any
incident involving minors and illegal sexual activity, or other types of abuse or neglect, they are legally required to report this to the
proper authorities.
I understand the above stated limits of confidentiality and mandated reporting responsibilities of my therapist and Family Strategies.
Client’s Signature Date
COURT REPORTS or LETTERS, COURT HEARINGS
_____ (initial) The therapists at Family Strategies do not write legal letters or court reports on behalf of clients involving divorce,
custody or other legal matters or lawsuits. We do not write letters pertaining to legal matters to any outside person (i.e. doctor, school,
attorney, etc.) or agency regarding your treatment. If a special circumstance arrives where a letter is required by court order, it will
require your written consent and will be billed to you at $25.00 per page and in addition to your therapist’s hourly fee.
As a general policy the therapists at Family Strategies are not forensic specialists and prefer to not testify or participate in court
proceedings on behalf of a client as that has the potential of changing the overall purpose and scope of our services. If you become
involved in legal proceedings that require mandated participation by your therapist, you will be expected to pay for all of your
therapist’s professional time including preparation and transportation time and costs, even if called to testify by another party
regarding your case. Because of the time involved and the interruption to your therapist’s clinical work and compensation, you will be
charged $350.00 per hour for preparation, travel, and attendance at any legal proceeding on your behalf. A detailed accounting of time
is available to you upon request.
Court fees can be very expensive. Please sign and date below to indicate that you understand your financial responsibility in covering
these expenses should we be mandated to go to court for a legal issue you are involved in. Your therapist is not a court advocate or
friend. A therapist must legally speak truthfully under oath.
Client’s Signature Date
THERAPY SESSIONS and FEES
_____ (initial) The fee for a standard therapy session at Family Strategies varies by therapist. The standard therapy session is 45 - 55
minutes in length. Therapy can be conducted in person in the office, via phone, or videoconference. It is understandable that
occasionally you may be late. If you are late to your session, please understand that the session will not extend past your allotted time,
nor will the time be made up at future sessions. Therapy sessions are paid via credit card, check, or cash. Please fill out the credit card
form included in this packet and bring with you to your first session. If paying with cash, please bring the exact cash amount for your
session fee as Family Strategies does not normally keep cash on premises.
Fees are reviewed annually and may increase periodically. The increase will be discussed with the client, and a 30-day notice will be
posted prior to the increase. Your therapist is happy to answer any questions you may have about this fee agreement. Please
understand that you have the right to terminate therapy at any point. If you have any questions regarding the fee policy, please do not
sign until discussing with your therapist.
APPOINTMENTS and CANCELLATIONS
_____ (initial) Appointment cancellations made less than 24 hours before the scheduled appointment will be charged the full agreed
upon fee for the session. If you do not show up for a scheduled appointment (that you have not called to cancel within 24 hours) you
will be charged the full fee for the session. You are responsible for keeping track of and attending your sessions. If you are sick or
experiencing any symptoms of illness, please call the office ahead of your appointment and ask to conduct your session via the phone
or videoconference. If your therapist is ill, the same consideration will be extended to you.
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THERAPIST AVAILABILITY BETWEEN SESSIONS
_____ (initial) Your therapist may be available to answer a short email regarding your therapy appointment times or therapy
homework no more than twice per month without charging a fee. We will not process therapy issues via email unless you have been
specifically instructed to do so as part of your treatment. If therapeutic services are required during non-business hours you will be
charged 25% of your therapist’s rate for every 15 minutes.
E-THERAPY - i.e. TELEMEDICINE, TELETHERAPY, CYBERTHERAPY, etc. (when applicable)
_____ (initial) E-therapy is the use of electronic media and information technologies to provide mental health services in different
locations. There are limitations and risks associated with e-therapy, including inherent confidentiality risks of electronic
communication and potential for technology failure. If there is an emergency and the therapist is unavailable, you should call 9-1-1. If
video is not available, the therapist will ask for identification. You will also be asked about your physical location during the
telemedicine encounter, as well as verification that the setting provides for your confidentiality.
Family Strategies does not allow either the counselor or client to record any portion of video or telephonic therapy sessions unless
prior consent has been obtained in writing for the purpose of training or supervision.
By signing below, you recognize that if there is an emergency and your therapist is unavailable, you should call 9-1-1. You also
acknowledge that if video is not available, your therapist will ask for identification. You will be asked to provide your therapist with
your physical location during the encounter, and verification that your setting provides for your confidentiality.
Client’s Signature Date
THERAPEUTIC APPROACH and STYLE
_____ (initial) Our goal at Family Strategies is to help people navigate through difficulties in their life and relationships while
providing a safe place to heal, explore, develop insight, practice healthy coping tools, and integrate and take responsibility for their
changes. Our therapeutic approach is collaborative, honest, challenging, and direct with solid boundaries and empathy. We use a
variety of client-centered modalities with clients.Your therapist may reflect, assist, encourage, and point out incongruent patterns
around actions and words. Your therapist will formulate the therapeutic plan collaboratively with you based on your needs, presenting
problems, and the goals you wish to achieve. At Family Strategies, we believe that each client has the potential for healing and
change, is responsible for their choices and changes, and for meeting their therapy goals – we do not make guarantees for healing.
INFORMED CONSENT
_____ (initial) Therapy is an interactive process between client and therapist, and the results of therapy depend on your cooperation.
Therapy is meant to promote change and understanding. Sometimes this process can be emotionally painful, and at other times, very
fulfilling. You will be expected to contribute to all decisions regarding therapeutic intervention devised for you, including out of
session assignments. You have the right to refuse or alter any service and intervention. While your therapist will use their best effort
to assist you, there can be no assurances of results, and no promises can be made regarding the outcome of any service provided. You
should question the rationale of any service, intervention, and discussion if these seem unclear to you. Your signature below indicates
that you understand that there are risks for noncompliance with treatment recommendations, and that you will discuss these risks with
your therapist.
GROUP THERAPY
_____ (initial) Due to the nature of group therapy, neither Family Strategies nor its therapists may release group records without
compromising the confidentiality of other participants, which is prohibited by Arizona law. All group records are stored “together” on
a single form, which makes individual notes for the group unavailable for copy and release. If you, as a client, require group records
for any legal reason, you (or your health care decision maker) must make such a request in writing, and Family Strategies and its
therapists are restricted to supplying only dates of service and general topics reviewed during classes and group sessions.
CLINICAL SUPERVISION
_____ (initial) Your therapist _________________________________is under clinical supervision as an associate licensed counselor
with the Arizona Board of Behavioral Health, or is a University intern studying for a Masters Degree, and provides therapy under the
clinical supervision of Dr. Floyd Godfrey,
PhD, Dr. Kim Buck, PhD, John Hinson, LPC, Abbie Ashton, LMFT, Angie Hatch, LPC,
and/or John McLean, LPC who are qualified to provide supervision within the state of Arizona according to the laws and regulations
set forth by the Arizona Board of Behavioral Health. You can contact any of the above mentioned supervisors by calling 480-668-8301.
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FINANCIAL RESPONSIBILITY
_____ (initial) You (or responsible party) are considered responsible for payment of professional services. When you request to bill a
third party, such as an insurance company, and that third party fails to make payment within 30 days from the date of billing, the client
or responsible party is expected to pay within 10 days of receipt of the statement. Bills not paid within 30 days from the date of billing
will be subject to an interest charge of 10% of the outstanding bill.
ROI CONSENT
_____ (initial) In an effort to provide me with the best possible care, I hereby authorize my therapist to exchange confidential
information regarding my treatment to other professional clinical staff at Family Strategies for the purpose of training, my own
therapeutic benefit, and coordination of my care. Professional staff includes, but are not limited to, the Executive Team, Supervisors,
therapists and interns who have expertise regarding specific clinical issues and treatment planning. If at any time it would be
advantageous for these individuals to participate in my treatment or visit sessions, I will give verbal consent for this to occur. I give
this authorization of my own free will and have discussed any questions or concerns with my therapist. By signing this consent to
exchange confidential information, I acknowledge that I have both read, understood and that I agree to all the terms of this release. I
understand that my records are protected under Federal and State Confidentiality Regulations. I understand that I may revoke my
consent at any time by written notice, and that my participation in Family Strategies’ treatment program(s) is conditional on the above
consent.
INFORMED CONSENT
I voluntarily agree to receive mental health assessment, care, treatment or services and authorize the undersigned therapist to provide
such. I understand and agree that I will participate in the planning of these services and that I may stop such care at any time. By
signing this consent form, I acknowledge that I have both read, understood and that I agree to all the terms and information contained
herein. Ample opportunity has been offered to me to ask questions and seek clarification on anything unclear to me. I also
acknowledge that I have received a copy of “Client Rights” and “Complaint/Grievance Procedures” as well as the “Notice of
Privacy Policies – HIPAA” documents.
Client Signature Date
Printed Name of Client
Therapist Signature Date
Signature of parent/legal guardian Date
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CONSENT FOR TREATMENT OF MINORS UNDER THE AGE OF 18
I, ________________________________________ (print name of legal guardian) am the parent or legal guardian with legal custody
of____________________________________________ (print name of client), and give permission to FS to provide counseling services for
my child.
NOTE: If parents are divorced, court custody documents must be provided prior to the first session. If parents share joint custody, both
must sign the "Client Consent" form.
TELEHEALTH CONSENT FORM
Revised 3.18.2021
I, ________________________________ (client) hereby consent to engage in Telehealth with __________________________________ (therapist).
I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g. Internet or
phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a client’s health care.
By signing this form, I understand and agree to the following:
1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the
confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to
confidentiality outlined in the Client Consent form I received from my therapist also apply to my Telehealth services.
2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable
efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be
disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my
treatment information could be accessed by unauthorized persons.
3. I understand that miscommunication between myself and my therapist may occur via Telehealth.
4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free
from distractions or intrusions.
5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.
6. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if
my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and refer me to in-person
services as needed. If such services are not possible because of distance or hardship, I will be referred to other therapists who can provide
such services.
7. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no
guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot be
guaranteed or assured.
8. I understand that Family Strategies does not allow either the counselor or client to record any portion of video or telephonic
therapy sessions unless prior consent has been obtained in writing for the purpose of training or supervision.
9. I have discussed the fees charged for Telehealth with my therapist and agree to them [or for insurance patients: I have discussed with my
therapist and agree that my therapist will bill my insurance plan for Telehealth and that I will be billed for any portion that is the client’s
responsibility (e.g. co-payments).
10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I
further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I
may call 911 or proceed to the nearest hospital emergency room for immediate assistance.
11. I have read and understand the information provided above, have discussed it with my therapist, and understand that I have the right to
have all my questions regarding this information answered to my satisfaction.
[For conjoint or family therapy, clients may sign individual consent forms or sign the same form.]
Client’s Signature Date
Client’s Printed Name
Verbal Consent Obtained: Therapist reviewed Telehealth Consent Form with Patient, Patient understands and agrees to the above advisements, and
Patient has verbally consented to receiving psychotherapy services from Therapist via Telehealth.
Therapist’s Signature Date
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CLIENT RIGHTS
CLIENT: The following pages are to be downloaded for your information. Please print a copy for your record and be prepared to confirm at your
first appointment that you have read and understood the information.
Arizona Statutes R9-10-1907, Office of Medical Licensing, requires that at the time of your initial appointment you be informed of your rights as a
client and, if applicable, the client’s parent, guardian, custodian, designated representative, or agent receive a copy of this document.
All clients shall be afforded the following basic rights:
1. The right to be treated with dignity, respect, and consideration;
2. The right to not be subjected to:
a. Abuse
b. Neglect
c. Exploitation
d. Coercion
e. Manipulation
f. Sexual abuse
g. Sexual assault
h. Restraint or seclusion
i. Retaliation for submitting a complaint to the Department or another entity
j. Misappropriation of personal and private property by a counseling facility’s personnel member, employee, volunteer, or student.
3. A patient, or the patient's representative, has the right to:
a. Either consent to or refuses counseling
b. Refuse or withdraw consent for receiving counseling before counseling is initiated
c. Is informed of the following:
i. The counseling facility’s policy on health care directives
ii. The patient complaint process
d. Consent to photographs of the patient before the patient is photographed, except that a patient may be photographed when
admitted to a counseling facility for identification and administrative purposes
e. Except as otherwise permitted by law, provides written consent to the release of information in the patient’s
i. Medical record
ii. Financial records.
4. The right to not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status,
or diagnosis;
5. The right to receive counseling that supports and respects the patient’s individuality, choices, strengths, and abilities;
6. The right to receive privacy during counseling;
7. The right to review, upon written request, the patient’s own medical record according to A.R.S. §§ 12-2293, 12-2294, and 12-2294.01;
8. The right to receive a referral to another health care institution if the counseling facility is not authorized or not able to provide the
behavioral health services needed by the patient;
9. The right to participate, or have the patient's representative participate, in the development of, or decisions concerning, the counseling
provided to the patient;
10. The right to participate or refuse to participate in research or experimental treatment; and
11. The right to receive assistance from a family member, the patient’s representative, or other individual in understanding, protecting, or
exercising the patient’s rights.
12. The right to review, upon written request, the client’s own record during the agency’s hours of operation or a time agreed upon by the
clinical director, except as described in R9-20-211(A)(6).
13. The right to review the following at the agency or at the “Department”: the A.A.C. Title 9, Chapter 20 Rules; the report of the most recent
inspection of the premises conducted by the “Department”; a plan of correction in effect as required by the “Department”; if the licensee
has submitted a report of inspection by a nationally recognized accreditation agency in lieu of having an inspection conducted by the
“Department”, the most recent report of inspection conducted by the nationally recognized accreditation agency; and if the licensee has
submitted a report of inspection by a nationally recognized accreditation agency in lieu of having an inspection conducted by the
“Department”, a plan of correction in effect as required by the nationally recognized accreditation agency.
14. The right to be informed of all fees that the client is required to pay and of the agency’s refund policies and procedures before receiving a
behavioral health service, except for a behavioral health service provided to a client experiencing a crisis situation.
15. The right to receive a verbal explanation of the client’s condition and a proposed treatment, including the intended outcome, the nature of
the proposed treatment, procedures involved in the proposed treatment, risks or side effects from the proposed treatment, and alternatives to
the proposed treatment.
16. The right to be offered or referred for the treatment specified in the client’s treatment plan.
17. The right to receive a referral to another agency if the agency is unable to provide a behavioral health service that the client requests or that
is indicated in the client’s treatment plan.
18. The right to give general consent and, if applicable, informed consent to treatment, refuse treatment or withdraw general or informed
consent to treatment, unless treatment is ordered by a court according to A.R.S. Title 36, Chapter 5, is necessary to save the client’s life or
physical health, or is provided according to A.R.S. 36-512.
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19. The right to be free from: abuse; neglect; exploitation; coercion; manipulation; retaliation for submitting a complaint to the “Department”
or another entity; discharge or transfer, or threat of discharge or transfer, for reasons unrelated to the client’s treatment needs, except as
established in a fee agreement signed by the client or the client’s parent, guardian, custodian, or agent; treatment that involves the denial of:
food, the opportunity to sleep, or the opportunity to use the toilet; and restraint or seclusion, of any form, used as a means of coercion,
discipline, convenience, or retaliation.
20. The right to participate or, if applicable, to have the client’s parent, guardian, custodian or agent participate in treatment decisions and in the
development and periodic review and revision of the client’s written treatment plan.
21. The right to control the client’s own finances except as provided by A.R.S. 36-507(5).
22. The right to participate, or refuse to participate, in religious activities.
23. The right to refuse to perform labor for an agency, except for housekeeping activities and activities to maintain health and personal hygiene.
24. The right to be compensated according to state and federal law for labor that primarily benefits the agency and that is not part of the client’s
treatment plan.
25. The right to participate, or refuse to participate, in research or experimental treatment.
26. The right to give informed consent in writing, refuse to give informed consent, or withdraw informed consent in writing, refuse to give
informed consent, or withdraw informed consent to participate in research or treatment that is not a professionally recognized treatment.
27. The right to refuse to acknowledge gratitude to the agency through written statements, other media, or speaking engagements at public
gatherings.
28. The right to receive behavioral health services in a smoke-free facility, although smoking may be permitted outside the facility.
COMPLAINT / GRIEVANCE PROCEDURE
There is an established process for resolving client complaints at Family Strategies Counseling Center. In the event you are dissatisfied with the
services you have received please:
1. Contact your counselor and advise them of your complaint. If not satisfied, contact:
2. The Executive Director of Family Strategies Counseling Center, Floyd Godfrey at (480) 668-8301, extension 1. You may make your
complaint by phone, mail, or in person. If the Executive Director is not available, you may contact the Assistant Director at (480)
668-8301, and leave a message if necessary. Every effort will be made to call you as soon as possible that same working day. Complaints
must be filed within 6 months of your last appointment. The complaint will be reviewed within 14 working days.
3. Once a decision is made on your complaint, you will be notified of the outcome within 30 days. If you are not satisfied, you may then
contact:
Arizona Department of Health Services
Office of Medical Licensing
150 North 18
th
Avenue, Suite #410, Phoenix, AZ 85007
(602) 364-2595
Division of Behavioral Health Services
150 North 18
th
Avenue, Suite #200, Phoenix, AZ 85007
(602) 364-4585
All Family Strategies Counseling Center Policies and Procedures, and documented reports are available for review upon request by appointment by
calling (480) 668-8301.
BEHAVIORAL OFFICE OF HUMAN RIGHTS ADVOCATES
Health Licensing Health Services
150 N. 18th Ave., 2nd Floor
Phoenix, AZ 85007 Phoenix, AZ 85007
602-364-4585
Arizona DES Child Protective Services
P.O. Box 44240
Phoenix, AZ 85064-4240
888-767-2445
Arizona DES Adult Protective Services
1789 W. Jefferson St
Phoenix, AZ 85007
877-767-2385
Arizona Center for Disability Law
5025 E. Washington St, Suite 202
Phoenix, AZ85034
602-274-6287
Regional Behavioral Health Authority:
Magellan Health Services of Arizona (Maricopa County)
4801 E. Washington St., Suite 100,
Phoenix, AZ 85034
800-564-5465
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NOTICE OF PRIVACY POLICY - HIPAA
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.
I. PROTECTED HEALTH INFORMATION (PHI): Family Strategies understands the importance of protecting health information
about our clients. Our practice creates records of care and services provided by therapists. These records are to provide our clients with
quality care as well as to comply with certain legal requirements. This notice is to inform you of the ways in which we may use and
disclose health information about you as well as to inform you of legal obligations to disclose. Your clinician is required by law to:
1. Make sure that protected health information (“PHI”) that identifies you is kept private.
2. Give you this notice of legal duties and privacy practices with respect to health information.
3. Follow the terms of the notice that is currently in effect.
4. Family Strategies can change the terms of this Notice, and such changes will apply to all information we have about you. The
new Notice will be available upon request.
II. HOW FAMILY STRATEGIES MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following
categories describe different ways that we use and disclose health information.
1. For Treatment, Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have
direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without
the patient’s written authorization, to carry out the health care providers own treatment, payment or health care operations.
This includes coordination with third party providers for referrals and consultations from one health care provider to another.
2. Family Strategies as an agency requires monthly staffing with clinicians. Your protected health information may be used in
coordination of staffing within the agency to provide quality care.
3. Lawsuits and Disputes: If you are involved in a lawsuit, we may disclose health information in response to a court or
administrative order. We may also disclose health information about your child in response to a subpoena, discovery request,
or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the
request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
1. Psychotherapy Notes. Family Strategies maintains “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and
any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For use in treating you.
b. For use in defending Family Strategies/Clinicians in legal proceedings instituted by you.
c. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
d. Required by law and the use or disclosure is limited to the requirements of such law.
e. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. Family Strategies will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. Family Strategies will not sell your PHI in the regular course of my business.
4. Even if you do have a signed authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop
any future uses and disclosures not needed of your PHI.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION: Subject to certain limitations in the
law, Family Strategies can use and disclose your PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law and the use or disclosure complies with, and is limited to, the relevant
requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a
serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
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4. For judicial and administrative proceedings, including responding to a court or administrative order, although the first priority
is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on our premises.
6. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind
you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or
other health care services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT:
Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is
involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be
obtained retroactively in emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask not to use or disclose certain
PHI for treatment, payment, or health care operations purposes.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on
disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health
care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way or to send mail
to a different address, and we will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or
paper copy of your medical record and other information that we have about you. We will provide you with a copy of your
record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may
charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures We Have Made. You have the right to request a list of instances in which we have
disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with
an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important
information is missing from your PHI, you have the right to request the correction of the existing information or add the
missing information.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you
have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also
have the right to request a paper copy of it.
VII. FILE A COMPLAINT IF YOU FEEL YOUR RIGHTS WERE VIOLATED:
1. You can complain if you feel we have violated your rights by contacting us at Family Strategies Counseling Center: 1745
South Alma School Rd, Mesa, AZ 85210, calling 480-668-8301, or emailing at admin@familystrategies.org.
2. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter
to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1- 877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/.
3. You will not be retaliated against for filing a complaint.
EFFECTIVE DATE OF THIS NOTICE: This notice went into effect on March 11, 2020.
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