Revealing Moments Counseling & Consultants, LLC
“Out of Darkness Comes Light”
CLIENT IDENTIFICATION
Name: _________________________________________ Sex: _____________DOB:___________________ Age: ____________
Address: ________________________________________________________________________________________________
City: ________________________________ State: __________________ Zip: ________SS#_____________________________
Driver’s License #__________________________________________________________
Primary Phone: ________________________________ Secondary Phone: ___________________________________________
Leave Message? Yes  No
Leave Message? Yes  No
Email Address: ___________________________________________________________________________________________
Emergency Contact: ____________________Relationship:____________________Phone:_______________________________
Currently Employed? Yes  No  If employed, company name: ___________________________________________________
How Long? ______ Occupation: _________________________________ Best time to call: ______________________________
 Check if the same as client (Skip this section)
RESPONSIBLE PARTY INFORMATION
Guardian Name: ______________________________________________ Sex: ___________ DOB: ______/_______/________
Relation to Patient: ______________________________ SS#_________________________ Employer: ____________________
Address: ________________________________________City: _______________________ State: _______________________
Primary Phone: ___________________________________ Cell Phone: _____________________________________________
FOR OFFICE USE ONLY
INSURANCE INFORMATION (please provide insurance card)
Policyholder’s Name: ______________________________________ Policyholder’s SS# _________________________________
Date of Birth: _______/_______/______
Primary Insurance Co. Name: ________________________________________
Insurance Co Customer Service Phone #: ________________________________________ Insurance ID# __________________
Co-Pay $ ___________
Deductible?  Yes or  No If yes, what is the amount $ _________________________________
Authorization Required?  Yes  No Authorization # ___________________________________________________________
Number of Sessions Authorized ________________
Maximum Number of Sessions Allowed Per Year ________________
Is the patient covered under a secondary insurance policy?  Yes  No
I, _______________________________________ (client or legal guardian) authorize CaRen Ogle, LPC/ Revealing Moments
Counseling & Consultants, LLC or any holder of medical information about me to release to my insurance company or its
representative, any information needed concerning the examination or treatment rendered to me that is necessary to process
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the insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical
insurance benefits to be paid directly to CaRen Ogle, LPC/Revealing Moments Counseling & Consultants, LLC in such amount as
my benefits allow. This authorization is effective until terminated in writing by the client or their guardian.
_________________________________________________
__________________________
Client or Legal Guardian Signature
Date
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE PROFESSIONAL SERVICES AGREEMENT AND AGREE TO ITS
TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPPA NOTICE FORM
DESCRIBED ON THE FOLLOWING PAGES.
PATIENT (OR PARENTS/GUARDIANS, IF PATIENT IS A MINOR)
__________________________________________________
___________________________
Signature of Client or Client (s) Parent (s)/Guardian (s)
Date
__________________________________________________
___________________________
Print Name of Client or Parents (s)/Guardian (s)
Relationship (s) to Client
OTHER ADULT PARTY/PARTIES INVOLVED IN TREATMENT
 NOT APPLICABLE
_________________________________________________
____________________________
Signature of Secondary Party/Parties
Date
_________________________________________________
____________________________
Print Name of Secondary Party/Parties
Relationship (s) to Client
_________________________________________________
____________________________
Signature of Therapist
Date
_________________________________________________
Print Name of Therapist
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CaRen Ogle, LPC
Revealing Moments Counseling & Consultants, LLC
(770) 309-2766
INTAKE CLINICAL ASSESSMENT FORM
Last Name :____________________________First Name:_______________
DOB:_______________ Age: ________________
Current Address: ________________________________________________________________________ How Long?________
Phone number: _______________________________ Alternative Number: __________________________________________
Form completed by (if someone other than client): ______________________________________________________________
Relationship Status: ____Single _____Married ______Separated ________Divorced _______Common Law _______Widowed
Please describe additional information (if needed) _______________________________________________________________
Sexual orientation: ____ Heterosexual ___ Lesbian/Gay ___ Bisexual ____ Other: _____________________________________
Number of Children: ______ Please note age/gender of each______________________________________________________
________________________________________________________________________________________________________
Indicate level of Education: ____ High School/GED ____ Vocational _____ College ______ Graduate School Graduated? _____
Currently Employed? ____ Yes ___ No With whom: _________________________________________ How Long? __________
Military Experience: ____ Yes ____ No Please explain (if needed) _________________________________________________
Emergency Contact: Name: ____________________________________ Phone number: ________________________________
Reason for Seeking Counseling: ______________________________________________________________________________
Please check behavior and symptoms experienced with your reason for seeking counseling:
___ Aggression
___ Chest Pain
___ Fatigue
___ Judgment errors
__ Stress
___ Alcohol
___ Depression
___Hallucinations
___ Loneliness
__ Sleep
___ Anger
___ Distractibility
___Hopelessness
___ Mood swings
__ Work
___ Antisocial behavior
___ Drugs
___ Impulsivity
___ Panic attacks
__ Worry
___ Anxiety
___ Eating Disorder
___ Irritability
___ Phobias
__ Other:
Please describe: __________________________________________________________________________________________
Please describe the impact checked items above are having on your life: _____________________________________________
_______________________________________________________________________________________________________.
DEVELOPMENT
Are there any special, unusual, or traumatic events that affected your development? _____ Yes ____ No
If yes, please describe: _____________________________________________________________________________________
Has there been a history of abuse? ___ Yes ___ No
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If yes, please select which type: ____ Verbal ____ Mental ____Emotional _____ Psychological _____ Physical ____ Sexual
FAMILY INFORMATION
Maternal
Relationship
Name
Age
Paternal
Living
Living with you
Yes
No
Yes
No
Mother
__________________________
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Father
__________________________
____
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___
___
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Spouse
__________________________
____
___
___
___
___
Brother (s)
__________________________
____
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__________________________
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Sister (s)
Grandmother
Grandfather
PARENTAL INFORMATION
___ Parents legally married How Long? ________
_____ Mother remarried: # of times; __________
___ Parents have ever been separated
_____ Father remarried: # of times: ___________
___ Parents ever divorced
Special circumstances (e.g. father had separate family, raised by someone else, information about another sibling/spouse):_
______________________________________________________________________________________________________.
CULTURAL/ETHNIC
To which cultural or ethnic group, if any, do you belong? ________________________________________________________
Are you experiencing any problems due to cultural or ethnic issues? ____ Yes ____ No
If yes, please describe: ____________________________________________________________________________________
Other cultural or ethnic information? ________________________________________________________________________
SPIRTITUAL/RELIGIOUS
How important to you are spiritual matters? ____ Not _____ Little ____ Moderate ____ Much
Are you affiliated with a spiritual or religious group? ____ Yes ____ No
If yes, please describe: _____________________________________________________________________________________
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Were you raised within a spiritual or religious group? _____ Yes
____ No
If yes, please describe: _____________________________________________________________________________________
Would you like your spiritual/religious beliefs incorporated into your counseling? _____ Yes ______ No
If yes, please describe: _____________________________________________________________________________________
CURRENT LEGAL STATUS
Are you currently involved in any active cases (traffic, civil, criminal)? _____ Yes ______ No
If yes, please describe and indicate the court and hearing/trial dates and charges: ____________________________________
________________________________________________________________________________________________________
Are you presently on probation or parole? ______ Yes _____ No
If yes, please describe: _____________________________________________________________________________________
LEISURE/RECREATIONAL
Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor, hunting, fishing,
etc.,):___________________________________________________________________________________________________
MEDICAL/PHYSICAL HEALTH
______ AIDS
____ Dizziness
_____ Nose bleeds
______ Alcoholism
____ Drug abuse
_____ Pneumonia
______ Abdominal pain
____ Epilepsy
_____ Rheumatic fever
______ Abortion
____ Ear infections
_____ Sexually transmitted disease
______ Allergies
____ Eating problems
_____Sleeping disorders
______ Anemia
____ Fainting
_____ Sore throat
______ Appendicitis
____ Fatigue
_____ Scarlet fever
______ Arthritis
____ Frequent urination
_____ Sinusitis
______ Asthma
____ Headaches
_____ Small pox
______ Bronchitis
____ Hearing problems
_____ Stroke
______ Bed wetting
____ Hepatitis
_____ Sexual problems
______ Cancer
____ High blood pressure
_____ Tonsillitis
______ Chest pain
____ Kidney problems
_____ Tuberculosis
______ Chronic pain
____ Measles
_____ Toothache
______ Colds/cough
____ Mononucleosis
_____ Thyroid problem
______ Constipation
____ Mumps
_____ Vision problems
______ Chicken pox
____ Menstrual pain
_____ Vomiting
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______ Dental problems
____ Miscarriages
_____ Whooping cough
______ Diabetes
____ Neurological disorders
_____ Other: _____________________
______ Diarrhea
____ Nausea
List any current medications: ________________________________________________________________________________
________________________________________________________________________________________________________
Family history of medical problems: __________________________________________________________________________
________________________________________________________________________________________________________
Please check if there have been any recent changes resulting from medical problems:
____ Sleep patterns
_____ Eating patterns
____ General disposition
_____ Weight
____ Behavior
___ Energy Level
___ Physical activity
____ Nervousness/tension ___ Other (s): ______________________________
CHEMICAL USE HISTORY
Is there any current/history of substance or alcohol use/abuse? ___ Yes ____ No
If yes, please describe: Substance of preference:
1. _______________________
Method: ___________
Frequency: ____ Age of first use: ______ Last Use:_______
2. _______________________
Method: ___________
Frequency:______ Age first used: _____ Last use: _______
Who first introduced you to the substance (s) listed above: ________________________________________________________
________________________________________________________________________________________________________
Reason (s) for use:
_____ Addicted
_____ Build confidence
_____ Escape
_____ Self-medication
____ Socialization
_____ Taste
_____ Other (specify): _________________________________________________________________
How do you feel your substance use affects your life? ________________________________________________________
____________________________________________________________________________________________________
Who or what has stopped or limited your use? _______________________________________________________________
_____________________________________________________________________________________________________
Does/has someone in your family present/past have/had a problem with drugs or alcohol? ____ Yes _____ No
If yes, please describe: __________________________________________________________________________________
_____________________________________________________________________________________________________
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COUNSELING/PRIOR TREATMENT HISTORY
Your reaction
Yes
No
When
Where
to overall experience_____
____
____
_____________
______________________
______________________
Attempts
____
____
_____________
______________________
______________________
Drug/Alcohol treatment
____
____
_____________
______________________
______________________
Hospitalizations
____
____
_____________
______________________
______________________
_____
____
_____________
______________________
______________________
Counseling/Psychiatric
Treatment
Suicide thoughts/
Involvement with self
help groups (AA, NA)
Does/has someone in your family present/past have/has received mental health treatment? ____ Yes _____ No
If yes, please describe: __________________________________________________________________________________
_____________________________________________________________________________________________________
I understand that after therapy begins I have the right to withdraw my consent to therapy at any time,
for any reason. However, I will make every effort to discuss my concerns about my progress with you
before ending therapy with you.
I understand that no specific promises have been made to me by this therapist about the results of
treatment, the effectiveness of treatment, or the number of sessions necessary for therapy to be
effective.
I have read, or have had read to me, the issues and points in this form. I have discussed the points I did
not understand, and have had any questions fully answered. I agree to act according to the points
covered in this form. I hereby agree to enter into therapy with this therapist, and to cooperate fully and
to the best of my ability, as shown by my signature.
Client Signature: _______________________________________________
Date: ________________________________
Print Signature: ________________________________________________
Therapist Signature: ____________________________________________
Print Signature: ________________________________________________
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Date: ________________________________
FOR STAFF USE ONLY
Critical Assessments:
Suicide Risk
none, active, passive, plan/means
Homicide/Violence Risk
no, yes, intent, plan/means
A&D Use:
none, low, medium, high
If yes, to any of the above Critical Assessments, describe in detail and intervention plan taken. If not, circle N/A:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Mental Status: appearance, affect, orientation, mood, thought content, thought process, intellect, insight, judgment, impulse
control, memory, concentration, attention, behavior, speech. ___Normal
___Any present
Thought Disorders: delusions, paranoia, ideas of reference, obsessions, confusion, flight of ideas. ___Normal ___ Any present
Axis I (clinical)____________________ Axis II __________ Axis III__________Axis IV __________________________________
GAF ____
_____81-90 Absent ____71-80 Transient/Expected _____ 61-70 Mild ____ 51-60 Moderate
____ serious: no friends, unable to keep job, impairment in reality, delusions, danger to self or others.
Therapist Signature & Credentials: __________________________________________ Date: _____/______/______
Therapist Printed Name & Credentials: ______________________________________ Date: _____/______/______
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Revealing Moments Counseling & Consultants, LLC
1109 West Peachtree St NW, Ste 700 Atlanta, GA 30309, (770)309-2766 Office
Release of Information Consent
Client’s Name:___________________________________________________________________
Address:___________________________________City:_________State:_____________Zip:_________
Phone:______________________________________ DOB:______________________________
I, ____________________________________, authorize ______________________________to:
_____________(send) ___________(receive)
the following _________ (to) ___________(from)
Name:________________________________________________________________________________
Address:___________________________________City___________State:___________Zip:__________
A separate authorization, as defined by HIPPA, is required for psychotherapy notes.
_____ Academic testing results
_____ Behavior programs
_____ Progress reports
_____ Intelligence testing results
_____ Medical reports
_____ Personality profile
_____ Psychological reports
_____ Psychological testing results
_____ Service plans
_____ Summary reports
_____ Vocational testing results
_____ Entire record, except progress notes
_____ Psychotherapy notes
_____ others, specify____________________________
The above information will be used for the following purposes:
_____ Planning appropriate treatment or program
_____ Continuing appropriate treatment or program
_____ Determining eligibility for benefits or program
_____ Case review ______Updating files
_____ Other (specify) ____________________________________________________________
I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable
Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records,
Chapter 1 and 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be
protected under these guidelines if they are not a health care provider covered by state or federal rules.
I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and
after (some states very, usually 1 year) this consent automatically expires. I have been informed what information will be given,
its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I
understand that I have a right to refuse to sign this authorization.
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Your relationship to client: ____Self ___Parent/Legal guardian ____ Legal representation
____ Other (describe)_________________________________
If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to
receive this protected health information.
Client’s Signature:____________________________ Date: ___/___/___
Parent/guardians/personal representative (if applicable)
Signature:___________________________________ Date: ___/___/___
Witness (if client is unable to sign)
Signature:___________________________________ Date: ___/___/___
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Notice of Privacy Practices
Revealing Moments Counseling & Consultants, LLC
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY Revealing Moments
Counseling & Consultants, LLC AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. This
notice is effective April 1, 2003. It is provided to you pursuant to provisions of the Health Insurance Portablility and
Accountability Act of 1996 (“HIPPA”) and related federal regulations. If you have questions about this Notice please contact
the Privacy Officer CaRen Ogle, LPC at 770-309-2766.
Revealing Moments Counseling & Consultants, LLC is a Limited Liability Company in the state of Georgia responsible for
providing a variety of professional services which deal with mental health and other confidential information. Both federal and
state laws establish strict requirements for most programs regarding the disclosure of confidential information, and Revealing
Moments Counseling & Consultants, LLC must comply with those laws. For situations where more stringent disclosure
requirements do not apply, this Notice of Privacy Practices describes how Revealing Moments Counseling & Consultants, LLC
may use and disclose any Protected Health Information (PHI) for treatment, payment, health care operations and for certain
other purposes. This notice relates only to health information. It describes your rights to access and control any PHI, and
provides information about your right to make a complaint if you believe Revealing Moments Counseling & Consultants, LLC has
improperly used or disclosed any “PHI”. Protected health information is information that may personally identify you or the
child(ren) and relates to any past, present or future physical or mental health or condition and related health care services.
Revealing Moments Counseling & Consultants, LLC is required to abide by the terms of this Notice of Privacy Practices, and may
change the terms of this notice, at any time. A new notice will be effective for all PHI that Revealing Moments Counseling &
Consultants, LLC maintains at the time of issuance. Upon receipt, Revealing Moments Counseling & Consultants, LLC will
provide you with a revised Notice of Privacy Practices by posting copies at its’ facilities, publication on Revealing Moments
Counseling & Consultants, LLC’s website, in response to a telephone or facsimile request to the Privacy Officer, or in person at
any facility where you receive services from Revealing Moments Counseling & Consultants, LLC.
1. USES AND DISCLOSURES OF PROTECTED HELATH INFORMATION
Any PHI may be used and disclosed by Revealing Moments Counseling & Consultants, LLC its’ employees, contractors, agents
and attorneys for the purpose of providing mental health services to you. Protected health information is routinely needed in
order to ensure proper mental health treatment.
Treatment: Any PHI may be used to provide, coordinate, or manage your or your child’s mental health services, including
coordination with a third party that has your permission to have access to any PHI, such as other health care professional who
may be treating you or your child(ren), a health care specialist or laboratory.
Payment: Your PHI or that of the child(ren) may be used to obtain payment for you or your child(ren)’s health care services.
Health Care Operations: Revealing Moments Counseling & Consultants, LLC may use or disclose any PHI to support the
business activities of Revealing Moments Counseling & Consultants, LLC including, but not limited to, quality assessment
activities, employee review activities, training, licensing, and other business activities. Revealing Moments Counseling &
Consultants, LLC may use a sign-in sheet at the registration desk at any facility or office where services are provided, You may
be asked to provide your name and other necessary information, and you may be called by name in the waiting room when a
staff member is ready to see you, and any PHI may be used to contact you about appointments and/or for other operational
reasons. Any PHI may be shared with third party “business associates” who perform various activities that assist us in the
provision of you or your child(ren)’s mental health services.
Other uses and disclosures of any PHI will be made only with your authorization, which you may revoke in writing at any time,
exception as permitted or required by law as described above.
Other Permitted or Required Uses and Disclosures With Your Authorization or Opportunity to Object
The Department may use and/or disclose any PHI to a court of law, to a family member, relative or any other persons you
identify on the Revealing Moments Counseling & Consultants, LLC Authorization Form. You have the opportunity to agree or
object to the use and/or disclosure of all or part of any PHI.
Permitted or Required Uses and Disclosures Without your Authorization or Opportunity to Object
Revealing Moments Counseling & Consultants, LLC may use or disclose any PHI without your authorization when required to do
so by law; for public health purposes, to a person who may be at risk of contracting a communicable disease, to a health
oversight agency, to an authority authorized to receive reports of abuse or neglect, in certain legal proceedings, and for certain
law enforcement purposes. Protected health information may also be disclosed without your authorization to a coroner,
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medical examiner or funeral director, for certain approved research purposes, to prevent or lessen a threat to health or safety,
and to law enforcement authorities for identification or apprehension of an individual.
Required Uses and Disclosures:
Under the law, Revealing Moments Counseling & Consultants, LLC must make disclosures to you, when required by the
Secretary of the Department of Health and Human Services and to investigate or determine the Department’s compliance with
the requirements of the Privacy Rule at 45 CFR Sections 164.500 et.seq.
2. YOUR RIGHTS UNDER THE FEDERAL PRIVACY RULE
The following is a statement of your rights with respect to any PHI and a brief description of how you may exercise these rights:
a. You have the right to inspect and copy your protected health information.
Upon written request, you may inspect and obtain a copy of any PHI for as long as the Department maintains the PHI. A
reasonable, cost-based fee for copying, postage and labor expense may apply. Under federal law you may not inspect or copy
information compiled in anticipation of, or for use in a civil, criminal, or administrative proceeding, or PHI that is subject to a
federal or state law prohibiting access to such information.
b. You have the right to request restriction of your protected health information.
You may ask in writing that Revealing Moments Counseling & Consultants, LLC not use or disclose any part of any PHI for the
purposes of treatment, payment or healthcare operations, and not to disclose PHI to family members or friends who may be
involved in your care. Such a request must state the specific restriction requested and to whom you want the restriction to
apply. Revealing Moments Counseling & Consultants, LLC is not required to agree to a restriction you request, and if Revealing
Moments Counseling & Consultants, LLC believes it is in your best interest to permit use and disclosure of any PHI, the PHI will
not be restricted, except as required by law. If Revealing Moments Counseling & Consultants, LLC does agree to the requested
restriction, Revealing Moments Counseling & Consultants, LLC may not use or disclose any PHI in violation of that restriction
unless it is needed to provide emergency treatment.
c. You have the right to request to receive confidential communication from us by alternative means or at an alternative
location. Upon written request, Revealing Moments Counseling & Consultants, LLC will accommodate reasonable requests for
alternative means for the communication of confidential information, but may condition this accommodation upon your
provision of an alternative address or other method of contact. Revealing Moments Counseling & Consultants, LLC will not
request an explanation from you as to the basis for the request.
d. You may have the right to request amendment of any protected health information. If Revealing Moments Counseling &
Consultants, LLC created any PHI, you may request in writing an amendment of that information for as long as it is maintained
by Revealing Moments Counseling & Consultants, LLC. Revealing Moments Counseling & Consultants, LLC may deny your
request for an amendment, and if it does so will provide information as to any further rights you may have with respect to such
denial.
e. You have the right to receive an accounting of certain disclosures Revealing Moments Counseling & Consultants, LLC has
made of any protected health information. This right applies only to disclosures for purposes other than treatment, payment
or healthcare operations, excluding any disclosures Revealing Moments Counseling & Consultants, LLC made to you, to family
members or friends involved in your care, or for national security, intelligence or notification purposes. Upon written request,
you have the right to receive legally specified information regarding disclosures occurring after April 1, 2011, subject to certain
exceptions, restrictions, and limitations.
f. You have the right to obtain a paper copy of this notice from Revealing Moments Counseling & Consultants, LLC.
3. COMPLAINTS RELATED TO USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION OR RIGHTS
You may complain to Revealing Moments Counseling & Consultants, LLC and to the Secretary of Health and Human Services if
you believe your health information privacy rights have been violated. You may file a complaint, in writing, with Revealing
Moments Counseling & Consultants, LLC which maintains any PHI. You must state the basis for your complaint. Revealing
Moments Counseling & Consultants, LLC will not retaliate against you for filing a complaint. You may contact the Privacy Officer
at 770-309-2766, or by mail to Attn: Privacy Officer, Revealing Moments Counseling & Consultants, LLC PO Box 663, Lithonia GA
30058 for further information about the complaint process, this notice, or your rights set forth above. Please sign a copy of this
Notice of Privacy Practices for Revealing Moments Counseling & Consultants, LLC’s records.
Client Signature: _______________________________________________
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Date: _______________________