Ashley Trice, MSW, LCSW
910 Broad Street
Durham, NC 27705
704-661-1715
ashleytricelcsw@gmail.com
Client Disclosure Form
Information and Consent for Treatment
Please fill out completely and use the back of the form as necessary.
Today’s date _________________________________________________________________________
Client’s Name________________________________________________________________________
Age & Date of Birth____________________________________________________________________
If treatment is for a couple or family, please list name(s) and age(s) of additional clients:
_____________________________________ Age & DOB_____________________________________
_____________________________________ Age & DOB_____________________________________
_____________________________________ Age & DOB_____________________________________
Address _____________________________________________________________________________
City, State, Zip _______________________________________________________________________
Home Phone: ________________________________________________________________________
Cell Phone: __________________________ Work Phone: ____________________________________
Do we have permission to call & leave a message? _____Yes _____No
Which phone number do you prefer? ______________________________________________________
Email Address (can a reminder be sent?) _____Yes _____No
___________________________________________________________________________________
Place of Employment: __________________________________________________________________
If student, school currently attending: ______________________________________________________
Emergency Contact__________________________________________Relationship to you___________
Emergency Contact Phone: _____________________________________________________________
By whom were you referred? ____________________________________________________________
May I have permission to thank them? ____ YES _____ NO
Please initial ______________________
What are you experiencing or what has happened that brings you to seek counseling?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Have you received previous counseling: _____YES _____NO (If Yes, please explain)
____________________________________________________________________________________
____________________________________________________________________________________
Current Medical Conditions______________________________________________________________
____________________________________________________________________________________
Current Medications:___________________________________________________________________
___________________________________________________________________________________
Primary Care Physician __________________________________Date of last physical______________
City & State of Primary Care Physician ____________________________________________________
Please bring this form to your first appointment.
Ashley Trice, MSW, LCSW
910 Broad Street
Durham, NC 27705
704-661-1715
ashleytricelcsw@gmail.com
Client Disclosure Form
Information and Consent for Treatment
I am pleased that you have chosen me for your counselor and look forward to meeting with you.
This document is designed to inform you of my standard policies and the professional practices
and relationship you can expect from me. I would appreciate you reading the information prior to
our first appointment.
Background and Training
I am a Licensed Clinical Social Worker. I hold a Masters of Social Work from UNC Chapel Hill. I
have years of experience working in diverse settings providing therapy for a wide variety of
issues.
Counseling Services and Approach
As a therapist, I believe that people make lasting change through interpersonal relationships. I
believe that effective therapeutic treatment occurs through a meaningful and reparative
relationship. In therapy, I focus on relationships and how these impact our past as well as
present relationships. I have experience with trauma, anxiety, depression, communication,
relationship, and attachment issues.
I have an eclectic approach to treatment that includes psychodynamic psychotherapy, CBT,
Structured Psychotherapy for Adolescents Responding to Chronic Stress, DBT, and solution
focused therapy. I enjoy both individual treatment as well as parent-child treatment and family
work. I work with children starting at age 11.
Sessions
I assure you that my services will be provided in a professional manner and will be consistent
with accepted ethical standards. Initial sessions will be an hour and fifteen minutes long with the
following sessions being 55 minutes. We will decide together on the frequency and appointment
times of sessions, which are generally once per week. You are financially responsible for your
regular appointment hour and I reserve this time for you. If you miss appointments, without
providing me notice 24 hours in advance, you will be charged the fee for a regular session.
Fees
My fee is $110 per 55 minute session. I am open to discussing sliding scale fees in person
depending on your financial situation. I contract with BCBS and some other insurance
companies will reimburse you for services if you file directly. If you anticipate difficulty with
payment, please discuss your concerns with me. Fees for counseling services are due in full at
the end of each session. Cash, personal check, or credit card is accepted.
If you choose to file for reimbursement from your insurance company, they may require
information regarding diagnosis, symptoms, treatment goals and methods. Any diagnosis
provided to your insurance company becomes a part of your permanent medical record.
Confidentiality
I regard the information you share with me with the greatest respect, so I want us to be as clear
as possible about how it will be handled. All information that we share, as well as my records of
our conversations, are confidential. There are five circumstances in which I cannot guarantee
confidentiality, either legally or ethically:
1)
If child abuse is suspected, the law requires I report it to the appropriate authorities.
2)
If elder abuse or dependent/impaired adult abuse is suspected, the law requires I
report it to the appropriate authorities.
3)
If the therapist believes that the client is in a clear and imminent danger to self or
others, other people will be contacted to prevent harm.
4)
If you use your medical insurance, your insurance company may inquire about your
therapy. No information other than your diagnosis and date of service will be
provided without a written consent for Release of Information from you. Please be
aware that I cannot control how your insurance company uses information about
you, and/or your dependent(s) once it is in their possession.
5)
In rare circumstances, therapists can be ordered by a Judge to release information.
In order to provide you with the best possible help, I will consult with my supervisor and I may
consult with other therapists who may have insights that will be of assistance, but only in such a
way that your confidentiality is fully preserved. Otherwise, I will not tell anyone anything about
your treatment, diagnosis, history, or even that you are a client, without your full knowledge and
a signed Release of Information form.
Please read carefully and complete the following section:
Please sign two copies of this form. One copy will be returned to you for your records, and I will
retain one copy in my confidential file.
1) I have read these policies and understand and accept them as described.
2) I hereby give permission and consent to AshleyTrice to provide treatment to me
and/or __________________________________ who is (are) my spouse/child(ren).
3) I understand that I am responsible financially for services rendered and the payment
is due in full each session.
4) I understand that I will be charged for appointments not canceled with 24 hours
notice.
5) I will pay $110 per session, as agreed upon with the therapist.
___________________________________
Name (Please Print)
______________________________
Client’s Signature
Date
___________________________________
Name (Please Print)
______________________________
Client’s Signature
Date
___________________________________
Therapist Signature
Date
Ashley Trice, MSW, LCSW
910 Broad Street
Durham, NC 27705
704-661-1715
ashleytricelcsw@gmail.com
Authorization for Release/Exchange of Information Form
This form provides Ashley Trice with written permission to communicate with other individuals
regarding your treatment (e.g., previous therapist, current health care providers, family
members).
I, ________________________, authorize Ashley Trice to release and/or exchange information
about my case with the following parties:
Name/Relation
Phone
Email or Address
Information to be Released or Exchanged (initial beside all that apply)
___ Intake & History
___ Treatment Progress
___ Diagnosis & Treatment Plan
___ Discharge Summary
___ Verbal Consultation
___ Billing & Payment
___ Other
This release shall be valid until the termination of treatment or until withdrawn in writing by the
client during the course of treatment.
Client Name: ________________________________________________________________
Client or Parent Signature if under 18: ____________________________________________
Date: ____________________________________________