HealthCircle Aging
Center
4863 North Nevada Avenue, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
CLIENT DATA FORM: INDIVIDUAL THERAPY
CLIENT NAME: ______________________________________ DATE: __________
DOB: ________ AGE:_______
STREET ADDRESS: ______________________________________
CITY: ______________________________ STATE: ____________ ZIP: __________
PHONE: ____________________________
E-MAIL: ______________________________________
CURRENT LIVING SITUATION: _________________ WITH WHOM DO YOU LIVE? ___________
DO YOU LIVE IN A RURAL AREA? Y N (Urban areas include: 80903-7, 80909-11, 80915-23)
HIGHEST GRADE IN SCHOOL COMPLETED/ DEGREE OBTAINED: _____________
CURRENTLY EMPLOYED? YES NO
CURRENT OCCUPATION (IF RETIRED, LIST FORMER OCCUPATION): _________________
ANNUAL INCOME RANGE (for research and grant funding): _________________________
NUMBER OF PEOPLE SUPPORTED BY INCOME: ___________
SOURCE OF INCOME: _________________________
DISABLED: Y N (If yes, please list disability): _________________________________
(While we consider the below questions important to offer you the best services possible, responses are optional.)
PARTNER STATUS: Divorced
Legally Separated
Married
Domestic Partner
Single
Widowed
GENDER: _________________________________
RACE/ETHNICITY: African-American/Black, American Indian, Asian, Hispanic/Latino, Native Hawaiian/Pacific
Islander, White, Multiracial
SEXUAL ORIENTATION: _________________________________
SPIRITUALITY/RELIGIOUS AFFILIATION: _________________________________
© Aging Center 12/2014
HealthCircle Aging
Center
4863 North Nevada Avenue, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
www.uccs.edu/agingcenter
Medication List
Name of Primary Physician: ______________________________________
Address: ______________________________________________________
Phone Number: __________________________
Fax Number: ____________________________
Prescription
Medications
Reason
Taken
Dose/ Frequency
Time of Day
(AM, PM, etc.)
Over-the-Counter
Medications
Reason
Taken
Dose/ Frequency
Time of Day
(AM, PM, etc.)
Please list your current health problems/conditions:
HealthCircle Aging
Center
4863 North Nevada Ave, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
CLIENT RIGHTS AND CONSENT TO TREATMENT
CLIENT: _______________________________________
DATE: _________________________
This information regarding your rights as a client is provided to you, as required by law. The Aging
Center is a university-based training and research facility, which specializes in preparing graduate students
for professional practice in psychology.
All mental health professionals are required by law to provide the following information to each client (or
their legal guardian) during the initial client contact, except in cases of emergencies and court ordered
situations:
Aging Center Clinician/Degree: ______________________________________________________
Supervisors Michael Kenny, Psy.D., P.C., License #1626
Brandon Gavett, Ph.D., License #3601
Carrie Bartell, L.C.S.W., License #876011
Daniel L. Segal, Ph.D., License #2054
Patricia Pirrello, Ph.D., License #1443
Business Address:
Business Phone:
Justin Lincoln, Psy.D. License # 3029
Cassie Faulhaber, Psy.D., License #3972
Miranda Shaw, Psy.D., License #3845
Sara H. Qualls, Ph.D., License #1092
4863 N. Nevada Ave., Suite #321
Colorado Springs, CO 80918
(719) 255-8002
1.
All Aging Center clinicians in training serve as clinical staff and receive on-going and intensive
supervision from qualified Licensed Psychologists and Licensed Clinical Social Workers. The
students in training at the Aging Center are not licensed in the State of Colorado. However, the
students in training follow the regulations set forth by the State of Colorado and the professional
ethics code.
2.
Recording of Clinical Sessions: Clients of the Aging Center are required to give signed consent for
the observation and recording of sessions to facilitate training needs and progress of therapy. The
information derived from observation or recording is not shared with anyone other than the Aging
Center staff members, in the context of professional consultation or supervision. The recording will
be erased following the supervisory or evaluation review.
3.
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental
Health Section of the Division of Registrations. We encourage discussing any concerns or
complaints you might have directly with the provider of your services, the supervisor of such
services, or the Aging Center Director, Dr. Michael Kenny. You can also contact the Colorado State
Board of Psychologist Examiners at 1560 Broadway, Suite 1350, Denver, CO, 80202, Phone: 303894-7766.
4.
Other Important Information:
a. Feel free to ask any questions about techniques used, the duration of the procedure, the reason
for any of the policies outlined in this form, or fees for services, at any time.
b. You may seek a second opinion from another clinician or may terminate our services at any time.
c. In a professional relationship, sexual contact is never appropriate and should be reported
immediately to the State Board of Psychologist Examiners.
5.
Confidentiality: The information provided by you as a client or caregiver/legal guardian is legally
confidential. There are exceptions to this confidentiality. Primarily these include:
a. A judge’s order, in a court of law, to reveal information.
b. If you provide your clinician with information about child abuse or elder abuse or that you intend
to harm yourself or someone else, including those identifiable by their association with a specific
location or entity, she or he is required by law to reveal that information to the appropriate
authorities or individuals, and/or person(s) responsible for the specific location or entity.
c. As of July 1, 2014, individuals 70 and older are considered at risk and situations involving
suspected abuse, caretaker neglect, and/or exploitation, must be reported to local law
enforcement.
d. Others are listed in the Notice of Privacy Rights that was provided to you.
6.
Fees: Client fees are determined on a sliding scale. Should you fail to pay your bill and decline to
make arrangements to pay off an outstanding balance, we reserve the right to use appropriate
collection procedures, including the use of a collection agency or court action.
7.
Cancellations: Except in cases of emergency or illness, therapy appointments must be cancelled at
least 24 hours ahead of time. Failure to do so may result in billing for the missed appointment.
8.
If you anticipate needing to bring a family member who is a care recipient to the Aging Center, please
discuss your situation with your therapist beforehand if possible. The Aging Center is not able to
provide supervision of care recipients who are left in our lobby. If resources are needed to help you
obtain coverage for your family member while you participate in services at the Aging Center please
talk with your therapist who can assist you. If your care recipient must accompany you to your
session, any assistance needed by your care recipient will result in your session being interrupted and
possibly rescheduled.
9.
The Aging Center is not able to provide emergency or crisis services. If you have an emergency,
please go to the nearest hospital or emergency room, or call the local mental health crisis line (6357000). If you anticipate or are experiencing acute distress, you and your therapist may decide to
schedule extra sessions and/or a plan to have brief phone consultations.
10. Future Contact Regarding Quality of Services: The Aging Center also may wish to contact you by
mail and/or telephone to seek your opinions about the quality of services received at the Aging
Center. Your cooperation with this effort will contribute to our efforts to improve services and make
them more widely available. Please indicate if you wish to be contacted regarding quality of services:
_____ No contact
_____Yes, mail and/or phone
_____Yes, mail only
Z:\EVERY CONCEIVABLE FORM\CLIENT RIGHTS AND CONSENT TO TREATMENT- INDIVIDUAL THERAPY 2/2015
2
RESEARCH DATA
1.
Use of Data for Research Purposes: With your permission, in order to advance the science of clinical
psychology, the data obtained from our services will be kept in a database and analyzed for research
purposes. All identifying information will be removed, so that it will be impossible to associate the
data with you. Participation in research is not required in order to receive services at the Aging
Center. Again, to ensure confidentiality, your name or other identifying information will not be
associated with the data. Examples of service data used in research are: test scores, types of services
received, ratings of service satisfaction, and levels of depression and anxiety. Please indicate if you
consent to the use of your data (which will not be associated with your identity):
_____Yes
2.
____No
Future Contact Regarding Opportunities for Research Participation: With your permission, you may
be contacted in the future and asked to participate in other research projects through the Aging
Center. On such occasion, you would be fully informed and asked for your consent to participate.
Participation in research is not required in order to receive services at the Aging Center. Please
indicate if you permit us to contact you in the future regarding participation in research projects:
_____Yes
____No
If you have questions regarding use of data for research, you may contact the principal
investigator and the Director of the Aging Center, Michael Kenny (719-255-8002). If you have
questions regarding your rights as a research participant or any concerns regarding use of your
de-identified data, you may report them – confidentially if you wish – to the UCCS Institutional
Review Board (719-255-3903).
IRB# 08-128, Exp 02/23/16
Explanation of types of mental health professionals:
A Licensed Psychologist must hold a doctoral degree in psychology and have completed post-doctoral
supervised practice.
Licensed Clinical Social Workers, Licensed Marriage and Family Therapists, and Licensed Professional
Counselors must hold a master’s degree in their profession and have completed post-masters supervised
practice.
Psychologist Candidates, Marriage and Family Therapist Candidates, and Licensed Professional
Counselor Candidates must hold the necessary degree and be in the process of completing required
supervised practice.
Certified Addiction Counselors must be a high school graduate and have completed required training and
supervised practice (CAC I & II), or must have a bachelor’s degree in behavioral health and have
completed additional training hours and supervised practice (CAC III).
A Licensed Addiction Counselor must have a clinical master’s degree and meet the CAC III requirements.
A Registered Psychotherapist is registered with the State, but is not licensed or certified, and is not
required to have any degree, training or experience.
I have read the preceding information and have also been given a verbal explanation. I understand my
rights as a client or as the client’s responsible party. I hereby consent to consultation, evaluation and/or
treatment by clinically qualified staff of the Aging Center.
Z:\EVERY CONCEIVABLE FORM\CLIENT RIGHTS AND CONSENT TO TREATMENT- INDIVIDUAL THERAPY 2/2015
3
_____________________________________
Client Signature
___________________________
Date
_____________________________________
Clinician Signature
___________________________
Date
_____________________________________
Supervisor Signature
___________________________
Date
Z:\EVERY CONCEIVABLE FORM\CLIENT RIGHTS AND CONSENT TO TREATMENT- INDIVIDUAL THERAPY 2/2015
4
HealthCircle Aging
Center
4863 North Nevada Avenue, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
www.uccs.edu/agingcenter
CLIENT ACKNOWLEDGEMENT OF
RECEIPT OF NOTICE OF PRIVACY PRACTICES
You May Refuse to Sign This Acknowledgement
I have received a copy of the Notice of Privacy Practices from ___________________________
I am a Caregiver Program client  YES  NO.
If YES, I have also received the UCCS Aging Center Complaint and Grievance Policy.
_______________________________________
Name (Print)
____________________________________
Signature
__________________
Date
For Office Use Only
We have made a good faith effort in attempting to obtain written acknowledgement of receipt of
the Notice of Privacy Practices. Acknowledgement could not be obtained for the following
reason(s):

Patient/Individual refused to sign.

Communications barriers prohibited obtaining an acknowledgement

An emergency situation prevented us from obtaining an acknowledgement

Other: _____________________________________________________________
Date of refusal: _______________________
Attempt was made by: _________________________________________ Date: ___________
© UCCS Aging Center 01/2014
CG Privacy Practices Acknowledgement (V1)
1
HealthCircle Aging
Center
4863 North Nevada Avenue, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
www.uccs.edu/agingcenter
AUTHORIZATION TO INFORM EMERGENCY CONTACT
In the event that my therapist, ________________________, is concerned about my safety
because he or she was unable to reach me at our scheduled appointment time, I give my
permission for my therapist to contact:
___________________________________________
Name
___________________________________________
Address
_______________
Phone
and to inform the above named person or agency about his or her concern.
I understand that no information will be released other than that related to the concern about my
safety, unless legal requirements relating to the reporting of threats of violence, harm, or child or
elder abuse or neglect apply.
This authorization will remain in effect from _______________, until the termination of my
therapy unless revoked by me in writing or by orally advising the Aging Center.
______________________________
Client or Guardian Signature
____________
Date
______________________________
Witness (Clinician) Signature
____________
Date
Emergency Contact Release 5/20/2009
HealthCircle Aging
Center
4863 North Nevada Avenue, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
www.uccs.edu/agingcenter
AUTHORIZATION TO RELEASE RECORDS AND INFORMATION
I, ___________________________________, give my permission to release copies of the
following records and/or information:_______________________________________________
about myself to/from_____________________________________________________________
(Name of Person/Agency/Organization/Physician)
______________________________________________________________________________
(Address)
__________________________________
(Phone)
__________________________________
(Fax)
This authorization will be in effect from _____________________, until___________________
(Date)
(Date)
I understand that I give my permission for the records and/or information to be obtained from or
released to only the person(s) or organization(s) indicated above, and relating only to the time
period(s) indicated above. I understand that if the information is released to my physician, it may
become part of my medical record in my physician’s office.
I understand that there are a few limited exceptions to these provisions in the Colorado Statutes.
These require the reporting of threats of violence, harm, or child or elder abuse and neglect (from
either evidence or suspicion), or when subpoenaed by the courts, to proper authorities. Certain other
exceptions exist and will be explained as necessary.
The UCCS Aging Center may not obtain or release records and/or information about me unless I
agree to the request to do so. I understand that I may revoke this consent at any time in writing, or if
I am physically unable to write, by orally advising the UCCS Aging Center, except to the extent that
the action has been taken thereon.
________________________________
Client or Guardian Signature
______________
Date
________________________________
Witness (Clinician) Signature
______________
Date
P:\EVERY CONCEIVABLE FORM\Authorization to Release Records and Information.doc
___ ___-___ ___-___ ___ ___ ___
Date of Birth
HealthCircle Aging
Center
4863 North Nevada Avenue, Suite 321
Colorado Springs, CO 80918
office 719-255-8002
fax 719-255-8006
THERAPY SLIDING SCALE FEE FORM
Number in household _______ Annual Household Income ____________ Available Assets _____________
(e.g., savings, properties, stocks, bonds)
Please indicate (CIRCLE): Annual household income range plus assets and number of persons
supported by this income.
Annual Household
Income + Available
Assets Range
$0
- 10,040
$10,041-13,386
$13,387-16,732
$16,733-20,078
$20,079-23,424
$23,425-26,770
$26,771-30,116
$30,117-33,462
$33,463-45,000
$45,001-60,000
$60,000- above
Number of Persons Supported by Income
1
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00
$35.00
$40.00
$50.00
$60.00
$75.00
2--3
$5.00
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00
$35.00
$45.00
$55.00
$70.00
4 or more
$5.00
$5.00
$5.00
$5.00
$10.00
$15.00
$20.00
$25.00
$40.00
$50.00
$60.00
The UCCS Aging Center is a non-profit agency and is dedicated to providing services on a low-fee,
sliding scale. If you feel that you are unable to pay the specified amount, please talk to your therapist or
the Clinic Administrator/Office Manager. Reduced fees from those listed above require proof of income.
I understand that I am responsible for a fee of $_________ to be paid at the beginning of each session. If
I cancel a session, it must be 24 hours in advance, or an emergency, or I will be charged for that session
and will be responsible for payment prior to my next session.
By signing this form, I agree that I have read and fully understand the above policies and conditions for
services.
____________________________
Client Signature
__________
date
____________________________________
Director’s signature required for reduced fee
Therapy Sliding Scale 11/2014
___________________________
Clinician Signature
___________
date
Geriatric Depression Scale
Name__________________________________ Date__________
Directions: Please answer all questions. Circle Yes or No
1. Are you basically satisfied with your life?.......................................................... YES
NO
2. Have you dropped many of your activities and interests?................................... YES
NO
3. Do you feel that your life is empty?.................................................................... YES
NO
4. Do you often get bored?...................................................................................... YES
NO
5. Are you hopeful about the future?....................................................................... YES
NO
6. Are you bothered by thoughts you can’t get out of your head?........................... YES
NO
7. Are you in good spirits most of the time?............................................................ YES
NO
8. Are you afraid that something bad is going to happen to you?........................... YES
NO
9. Do you feel happy most of the time?................................................................... YES
NO
10. Do you often feel helpless?............................................................................... YES
NO
11. Do you often get restless and fidgety?.............................................................. YES
NO
YES
NO
13. Do you frequently worry about the future?....................................................... YES
NO
14. Do you feel you have more problems with memory than most?....................... YES
NO
15. Do you think it is wonderful to be alive now?.................................................. YES
NO
16. Do you often feel downhearted and blue?.......................................................... YES
NO
17. Do you feel pretty worthless the way you are now?.......................................... YES
NO
18. Do you worry a lot about the past?.................................................................... YES
NO
19. Do you find life very exciting?.......................................................................... YES
NO
20. Is it hard for you to get started on new projects?................................................ YES
NO
21. Do you feel full of energy?................................................................................. YES
NO
22. Do you feel that your situation is hopeless?....................................................... YES
NO
23. Do you think that most people are better off than you are?................................ YES
NO
24. Do you frequently get upset over little things?.................................................. YES
NO
25. Do you frequently feel like crying?................................................................... YES
NO
26. Do you have trouble concentrating?.................................................................. YES
NO
27. Do you enjoy getting up in the morning?............................................................YES
NO
28. Do you prefer to avoid social gatherings?......................................................... YES
NO
29. Is it easy for you to make decisions?................................................................. YES
NO
30. Is your mind as clear as it used to be?............................................................... YES
NO
12. Do you prefer to stay at home, rather than going out and doing new things?
Geriatric Anxiety Scale (GAS)
© Daniel L. Segal, Ph.D., 2014
Below is a list of common symptoms of anxiety or stress. Please read each item in the list carefully.
Indicate how often you have experienced each symptom during the PAST WEEK, INCLUDING TODAY
by checking under the corresponding answer.
Not at
all (0)
1. My heart raced or beat strongly.
2. My breath was short.
3. I had an upset stomach.
4. I felt like things were not real or like I was
outside of myself.
5. I felt like I was losing control.
6. I was afraid of being judged by others.
7. I was afraid of being humiliated or
embarrassed.
8. I had difficulty falling asleep.
9. I had difficulty staying asleep.
10. I was irritable.
11. I had outbursts of anger.
12. I had difficulty concentrating.
13. I was easily startled or upset.
14. I was less interested in doing something I
typically enjoy.
15. I felt detached or isolated from others.
16. I felt like I was in a daze.
17. I had a hard time sitting still.
18. I worried too much.
19. I could not control my worry.
20. I felt restless, keyed up, or on edge.
21. I felt tired.
22. My muscles were tense.
23. I had back pain, neck pain, or muscle
cramps.
24. I felt like I had no control over my life.
25. I felt like something terrible was going to
happen to me.
26. I was concerned about my finances.
27. I was concerned about my health.
28. I was concerned about my children.
29. I was afraid of dying.
30. I was afraid of becoming a burden to my
family or children.
Sometimes
(1)
Most of
the time
(2)
All of the
time (3)
Protocol Number: 14-251
Version and Date Received: ROC(1) V1, 7/8/15
Consent to be a Research Subject
Protocol #:
14-251
Title: The UCCS Research Registry
Principal Investigator: Michele Okun, PhD
Funding Source: N/A
Introduction
UCCS and The Lane Center for Academic Health Sciences are actively seeking adults to participate in research studies.
To that end, we are collecting names to form a Participant Registry database. This form is designed to tell you everything
you need to think about before you decide to consent (agree) to be a part of this Registry. A member of the research
team will describe the process to you and answer any questions. It is entirely your choice. If you decide to take part,
you can change your mind later on and withdraw from the research registry. You can skip any questions that you do
not wish to answer.
This Database contains names of individuals who have expressed an interest in participating in research studies at UCCS.
If you decide to participate, we will record your name, and other demographic information such as gender, year of birth,
race, ethnicity, veteran/military status, phone number, email, and mailing address. Even if you decide not to provide all
of this information, you can still be added to the database.
Before making your decision:
 Please carefully read this form or have it read to you.
 Please ask questions about anything that is not clear.
Feel free to take your time thinking about whether you would like to participate. By signing this form you will not give up
any legal rights. If you are completing this consent form online, you may want to print a copy of the consent form for
your records.
Overview: We are asking your permission to put contact and minimal demographic information about you in a UCCS
Research Registry database. This research registry will allow UCCS investigators to find individuals, such as you, who
may want to take part in research. The information we are collecting includes basic information and other demographic
information such as gender, year of birth, race, ethnicity, veteran/military status, phone number, email, and mailing
address. We are asking all residents of the Pikes Peak region who are 18 years of age or older to participate.
Procedures: If you agree to participate in this research registry, your contact information will be provided to the
researchers who place a written request with the designated data manager. Only if you meet minimum eligibility
requirements, such as age or gender, will your contact information be provided to the researcher. You may then be
contacted by a researcher (via mail, phone or email) who will talk to you about a specific study. If you sign up for the
research registry, you can still refuse to take part in any (future) research study. If you decide to take part in any
research study, you must sign a separate consent form for that study.
Other people in this study: We are asking all residents of the Pikes Peak region (~300000) 18+ years if he/she would be
willing to be added to the Research Registry in order to be contacted for future research purposes.
Risks and Discomforts: We anticipate minimal risk or discomfort with this data collection. You may have concerns about
the information being collected and whether it can be connected back to you. In order to address this potential
discomfort/risk, we are not collecting any personal identifying medical information from you. You will have full access to
Page 1 of 3
Version Date: 05/22/2014
Protocol Number: 14-251
Version and Date Received: ROC(1) V1, 7/8/15
clinical services at any UCCS related clinic even if you do not wish to have your data used for research purposes.
Services are not contingent on agreeing to have information used for future research purposes.
Benefits: There are no anticipated benefits from being in this registry. However, if you do choose to participate in
specific research study from which your information was provided, you may realize direct benefit from that.
Compensation: Compensation is not provided for signing up for the registry.
Confidentiality: None of your contact information will be publicly available. All information will be maintained in a
password, encrypted database. Requesting investigators are likewise obligated to maintain your confidential
information. You will not be specifically identified in any publication of research results. Only the individual consenting
you and the Database Manager will be aware of your identity. Your information will be entered into a password
protected and firewalled database that is only accessible by the Data Manager.
Certain offices and people other than the researchers may have access to registry records.
Government agencies and UCCS employees overseeing proper study conduct may look at your registry records. These
offices include the:
UCCS Institutional Review Board
UCCS Office of Sponsored Programs
UCCS will keep any research records confidential to the extent allowed by law. A study number rather than your name
will be used on registry records wherever possible.
Registry records may be subject to disclosure pursuant to a court order, subpoena, law or regulation.
Voluntary Participation and Withdrawal from the Study
Taking part in this study is voluntary. You have the right to leave a study at any time without penalty. You may refuse to
do any procedures you do not feel comfortable with, or answer any questions that you do not wish to answer. If you
withdraw from the study, you may request that your research information not be used by contacting the Principal
Investigator listed above and below.
Contact Information
Contact (PI’s info): Michele Okun, PhD; 412-302-8030; mokun@uccs.edu
 if you have any questions about this registry or your part in it
Contact the Research Compliance Specialist at 719-255-3903 or via email at irb@uccs.edu:
 if you have questions about your rights as a research participant, or
 if you have questions, concerns or complaints about the research.
Consent
A copy of this consent form will be provided to you.
I understand the above information and voluntarily consent to participate in the research. I choose to be in this registry.
By signing this consent, I am confirming that I am 18 years of age or older.
Signature of Participant
Page 2 of 3
Date
Version Date: 05/22/2014
Protocol Number: 14-251
Version and Date Received: ROC(1) V1, 7/8/15
Please complete any or all of the following items:
Name: ____________________________________
Gender:
Your Year of Birth: ___________________
Phone #: ___________________________
Address: _____________________________________
Email:______________________________
_____________________________________________
Preferred method of contact: Email
Please circle your ethnicity:
1. Hispanic
Please circle your race:
1. White
2. Black or African American
3. Native Hawaiian or Other Pacific Islander
4. American Indian or Alaska Native
5. Asian
6. More than one race
7. Other or unknown
Page 3 of 3
male
female
Phone
2. Non-Hispanic
Please indicate your veteran or military status:
1. Veteran
2. Active Military/Reserve
3. Civilian
4. Other/NA (indicate):______________________
Version Date: 05/22/2014