Copyright © 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult

Name: ___________________________ Age: ____ Sex: � Male � Female Date:________ If this questionnaire is completed by an informant, what is your relationship with the individual? ___________________ In a typical week, approximately how much time do you spend with the individual? ____________________ hours/week

Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems?

None Not at

all

Slight Rare, less than a day

or two

Mild Several

days

Moderate More than

half the days

Severe Nearly every day

Highest Domain

Score (clinician)

I. 1. Little interest or pleasure in doing things? 0 1 2 3 4

2. Feeling down, depressed, or hopeless? 0 1 2 3 4

II. 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4

III. 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4

5. Starting lots more projects than usual or doing more risky things than usual?

0 1 2 3 4

IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4

7. Feeling panic or being frightened? 0 1 2 3 4

8. Avoiding situations that make you anxious? 0 1 2 3 4

V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4

10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4

VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4

VII. 12. Hearing  things  other  people  couldn’t  hear,  such  as  voices  even  when  no  one was around?

0 1 2 3 4

13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?

0 1 2 3 4

VIII. 14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4

IX. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?

0 1 2 3 4

X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 0 1 2 3 4

17. Feeling driven to perform certain behaviors or mental acts over and over again?

0 1 2 3 4

XI. 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?

0 1 2 3 4

XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4

20. Not feeling close to other people or enjoying your relationships with them? 0 1 2 3 4

XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 0 1 2 3 4

23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s  prescription,  in  greater  amounts  or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]?

0 1 2 3 4

Copyright © 2000–2011 by Dr. John M. Gottman and Dr. Julie Schwartz Gottman. Distributed under license by The Gottman Institute, Inc.

Your Name:__________________ ID______________ Date: ___________________

Suicide Potential Questionnaire

1. Have you ever attempted suicide ? � Yes � No2. Have you ever planned a suicide attempt ? � Yes � No

3. Are you currently thinking about suicide ? � Yes � No

How often? Daily � Weekly �

4. Does the following describe you at the moment?

“I would like to kill myself” � Yes � No “I would kill myself if I had a chance” � Yes � No5. Do you currently have a suicide plan? � Yes � No

I N T A K E F O R M Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information. Please fill out this form and bring it to your first session. Name: ______________________________________________________________ (Last) (First) (Middle Initial) Name of parent/guardian (if under 18 years): ____________________________________________________________________ (Last) (First) (Middle Initial) Birth Date: ______ /______ /______ Age: ________ Gender: Ƒ�0DOH��Ƒ�)HPDOH Marital Status: Ƒ�1HYHU�0DUULHG Ƒ�'RPHVWLF�3DUWQHUVKLS Ƒ�0DUULHG Ƒ�6HSDUDWHG Ƒ�'LYRUFHG Ƒ�:LGRZHG Please list any children/age: _________________________________________________ Address: ________________________________________________________________

(Street and Number) ________________________________________________________________________

(City) (State) (Zip) Home Phone: ( ) May we leave a message? Ƒ�<HV���Ƒ�1R Cell/Other Phone: ( ) May we leave a message? Ƒ�<HV���Ƒ�1R E-mail: _________________________________________ May we email you? Ƒ�<HV�Ƒ�1R *Please note: Email correspondence is not considered to be a confidential medium of communication. Referred by (if any): _______________________________________________________ Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Ƒ�1R� Ƒ�<HV��SUHYLRXV�WKHUDSLVW�SUDFWLWLRQHU��BBBBBBBBBBBB_____________________________

Are you currently taking any prescription medication? Ƒ�<HV Ƒ�1R Please list: _______________________________________________________________ ________________________________________________________________________ Have you ever been prescribed psychiatric medication? Ƒ�<HV Ƒ�1R Please list and provide dates: _________________________________________________ _________________________________________________________________________ GENERAL HEALTH AND MENTAL HEALTH INFORMATION 1. How would you rate your current physical health? (please circle) Poor Unsatisfactory Satisfactory Good Very good Please list any specific health problems you are currently experiencing: ________________________________________________________________________ 2. How would you rate your current sleeping habits? (please circle) Poor Unsatisfactory Satisfactory Good Very good Please list any specific sleep problems you are currently experiencing: ________________________________________________________________________ 3. How many times per week do you generally exercise? __________ What types of exercise to you participate in? ____________________________________ 4. Please list any difficulties you experience with your appetite or eating patterns: ________________________________________________________________________ 5. Are you currently experiencing overwhelming sadness, grief, or depression? Ƒ�1R Ƒ�<HV If yes, for approximately how long? ___________________________________________

6. Are you currently experiencing anxiety, panic attacks, or have any phobias? Ƒ�1R Ƒ�<HV If yes, when did you begin experiencing this? ___________________________________ 7. Are you currently experiencing any chronic pain? Ƒ�1R Ƒ�<HV If yes, please describe: _____________________________________________________ 8. Do you drink alcohol more than once a week? Ƒ�1R Ƒ�<HV� 9. How often do you engage recreational drug use?

Ƒ�'DLO\ Ƒ�Weekly Ƒ�Monthly Ƒ�,QIUHTXHQWO\ Ƒ�1HYHU 10. Are you currently in a romantic relationship? Ƒ�1R Ƒ�<HV� If yes, for how long? __________________ On a scale of 1-10, how would you rate your relationship? __________ 11. What significant life changes or stressful events have you experienced recently: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ FAMILY MENTAL HEALTH HISTORY: In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.). Please Circle List Family Member Alcohol/Substance Abuse yes/no Anxiety yes/no Depression yes/no Domestic Violence yes/no Eating Disorders yes/no Obesity yes/no Obsessive Compulsive Behavior yes/no Schizophrenia yes/no Suicide Attempts yes/no

ADDITIONAL INFORMATION: 1. Are you currently employed? Ƒ�1R Ƒ�<HV If yes, what is your current employment situation? ________________________________________________________________________ Do you enjoy your work? Is there anything stressful about your current work? ________________________________________________________________________ ________________________________________________________________________ 2. Do you consider yourself to be spiritual or religious? Ƒ�1R Ƒ�<HV� If yes, describe your faith or belief: ________________________________________________________________________ 3. What do you consider to be some of your strengths? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 4. What do you consider to be some of your weaknesses? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5. What would you like to accomplish out of your time in therapy? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Client Intake Additional Information

Additional Information Very Briefly fill out the following

Birth Family Your initials ______________ Date __________________

What is your birth order (first, second, middle)? ____________________________

Did you mother and father stay together? (yes/no) ______

If they did not, how old were you when they split up? __________

Use three words to describe the family environment (e.g. competitive, fun, loving, hostile, neglectful, etc.) ________________________, __________________________, ______________________

Development

Was there anything of note in your development? (e.g. brain injury, held back a grade, moved up a grade, diagnosed with a learning disability, etc.) - briefly describe___________________________________________________________________________

___________________________________________________________________________

Education

Please write your highest level of education completed (GED, HS diploma, Bachelors Degree, Ph.D., etc.) __________________________

Legal

Please list any significant legal issues you have experienced in the past (e.g. felony assault, prison sentence, etc.) _______________________________________________________

If you have been incarcerated, please write for how long: ___________________________

Please describe important details regarding your case: ___________________________________________________________________________

___________________________________________________________________________

Home

Please take a moment and briefly describe your current living situation (e.g. married living with children, single living alone, living with room mate, etc)._______________________

Use three words to describe your current home environment (e.g. fun, loving, hostile, lonely, etc.) ________________________, __________________________, ______________________

Client Emergency Contact

Your Full Name

Date

Emergency Contact 1

Full Name

Phone

Cell Phone

Relationship

Emergency Contact 2

Full Name (if necessary)

Phone

Cell Phone

Relationship

Christopher McBride, MALMHC, C.Ht, EMDR Provider

Discover - Recover - Optimize6855 W Clearwater Ave #B Phone: (509) 619-7350Kennewick WA, 99336 web: http://www.christopher-mcbride.com

HIPPA Police Update: I acknowledge that I have read the article known as the HIPPA Notice for

consumers. I understand that my information may be shared (or not shared) according to the details in

that document. I acknowledge that I may receive a copy of the HIPPA notice upon request and that

Christopher McBride, LMHC abides by the statues contained therein.

_______________________________ ________________________________

Your Signature Date

________________________________

Your Printed Name

Christopher McBride MA, LMHCA, C.Ht, 8390 W.Gage Blvd #213 Kennewick, WA 99336 (509) 619-7350

Christopher McBride, MALMHC, C.Ht, EMDR Provider

Discover - Recover - Optimize6855 W.Clearwater Ave #B Phone: (509) 619-7350Kennewick WA, 99336 Fax: (509) 621-1009

web: http://www.christopher-mcbride.com

Appointment Reminder Agreement -

I agreed to ‘opt-in’ to automated reminders. I understand that reminders may be delivered via email, text

message (SMS) or via automated phone message. I acknowledge that these methods of communication

may not be secure and thus confidentiality can not be guaranteed. I acknowledge that I may opt out of automated reminders by notifying Christopher McBride in writing via email, SMS or U.S. mail.

Please select one contact method you prefer below:

Method - Circle (Yes or No) -Enter the number

___________________________

Your Name

___________________________ _______________________________ Your Signature Date

Contact Method Circle Yes or No Enter contact info

Text Yes | No ( )______-________________

Phone Call Yes | No ( )______-________________

Email Yes | No _______________________@__________________________

Christopher McBride MA, LMHC, C.Ht, 6855 W Clearwater Ave #B Kennewick, WA 99336 (509) 619-7350

Christopher McBride, MA, LMHC6855 W Clearwater Ave ste B Kennewick WA 99336 Phone: 509-691-7350 Fax: 509-621-1009Payment and Insurance Form:

Name of Insured: _______________________________ Insured Birthday _____/_____/______

Address of Insured: ___________________________________________________________

Relation of client to insured person _______________________________________________

Insurance Company: ____________________________Phone:_________________________

Insurance Identification Number ____________________ Group Number _________________

Patient or Authorized Person’s Signature, I authorize the release of any medical or other information necessary to process a claim. I also request payment of government benefits to myself or to the party who accepts assignment. I authorize payment of medical benefits to the provider of services. I agree to pay any amount not covered by insurance.

____________________________________ ____________________________Signature Date

Private Pay:

I agree that private pay rates are due at time of service. I agree that, if I’m using a debit/credit card, to incur a $2.00 convenience fee per swipe in addition to rate listed above. Discount for cash/check pay = ____.___% or ____.___ amount.

____________________________________ ____________________________Name Date

____________________________________Signature

Intake Session/After 5 PM

$130/160 Documentation/letters (in 15 minute intervals)

$45.00

Therapy Sessions/After 5 PM

$100/$120 Preparation for Legal Proceedings (per hour)

$200.00

Couples Sessions/after 5 PM

$100/120 Participation in Legal Proceedings (1st hour)

$500.00

Families/after 5 PM $100/120 Participation in Legal Proceedings (After 1st hour)

$200.00

Re-occurring & Missed Session Credit Card Authorization Form

Christopher McBride, MA, LMHC (509) 619-7350

6855 W Clearwater Ave #B Kennewick, WA 99336

Authorization for Recurring Credit Card Charges

For Regular sessions, Intakes, late cancellations or no shows, you authorize recurring

charges to your credit card. For cancellations/no shows, you will be charged the day

of your missed therapy appointment unless other arrangements have been made. The

charge will be made under the name Christopher McBride, MA, LLC.

Name of Client_____________________________________________

Account Type: Visa MasterCard American Express,(AmEx) Discover

Cardholder Name ____________________________________________

Account Number _____________________________________________

Expiration Date ____________

CVV (3-digit number on back of Visa, MasterCard, or Discover; 4 digits on front of AmEx)

________

I authorize Christopher McBride, MA to charge this credit card for professional services and

associated charges as agreed below. These charges may include:

• Charge for cancellation without 24 hours’ notice: $__50.00________

• Normal Session fees agreed upon in contract as requested.

• A $2 bank/convenience fee is charge per credit card swipe for any fees $50.00 and over.

I understand that this authorization will remain in effect until I cancel it in writing,

and I agree to notify this practice in writing of any changes in my account information

or termination of this authorization at least 15 days prior to the next billing date.

Signature of Authorized Credit Card User:

_______________________________________

Your Name

_______________________________________

Your Signature

Date:_______________________

CAUPhDPracticumManualPage16

I, ______________________________, give _Christopher McBride , LMHC_, (client or client's parent or guardian) (counselor-in-training) permission to video record our counseling sessions. I understand that my counselor is (a) a graduate student in counseling, (b) may not yet licensed, and (c) is under the supervision of a qualified clinical supervisor. I understand that the sole use for these recordings is to increase the effectiveness of the counselor-in-training by provision of instruction and feedback. Review of recordings of any session may occur by both an on-site supervisor and the OSU clinical supervision team. I understand that session recordings are destroyed in a HIPAA-compliant manner within a month of the date of the recording. I understand that the confidentiality of these recordings will be preserved by my counselor and his/her clinical supervisors in accordance to state law, federal law, and the ethical standards off the American Counseling Association.“ I understand that concerns about suicide, homicide, or child abuse may place limitations on confidentiality, in that the safety of individual lives is considered a priority to holding information confidential. Where lives are at risk, ethical and legal obligations of the profession dictate communication with official resources that may prevent loss of life or childhood injury. ___________________________ Client Signature __________________________ Counselor-in-Training Signature ___________________________________________________ Signature of Parent or Guardian if Client is a Minor ___________ Date

104 Furman Hall, Corvallis, Oregon 97331-3502 T 541-737-4661 | F 541-737-8971| http://oregonstate.edu/education

PERMISSION TO VIDEO TAPING THERAPY SESSIONS

I/We_____________________________________________ (your name/names) consent to the video taping of therapy sessions with _Christopher McBride, LMHCA_. I/We are aware of the presence of the video equipment and permit the use of all or part of the video tapes for the purpose of: Supervision, case review and educational purposes.

_____ (initial) Our therapist to assist in our therapy for educational review.

_____ (initial) Our therapist’s consultation with a clinical supervisor(s) and/or training group. _____ (initial) Use for certification board or other higher learning board/committee

In no way will the refusal to grant consent for this video taping effect my/our getting assistance for myself/ourselves. If at any time during the treatment process, we wish to stop the taping we may do so and still continue treatment.

____________________________ ____________________________ Signature Signature

____________________________ ____________________________ Your Name Your Name

____________________________ ____________________________ Date Date

Therapist’s Signature: ____________________________________

Therapist’s Printed Name: __Christopher McBride, MA, LMHCA___

Date: _____________________________

Disclosure statement Page � of �1 2

6855 W CLEARWATER AVE #B KENNEWICK WA 99336 (509) 619-7350

STATE OF WASHINGTON REQUIRED DISCLOSURE

Christopher McBride,MA, LMHC State of Washington Licensed Mental Health Counselor LH60659218 & Registered Hypnotherapist, #HP60304073

This disclosure statement provides information about the treatment provider and the treatment offered, to assist you in choosing the treatment and the provider best suited to your needs.

My Approach to Treatment Individuals, couples and families may struggle from time to time. Whether from social learning, individual learning, genetics or traumatic events we all pick-up tendencies that may negatively effect us later on in life. Many times in life what we adapt to a challenge and that adaptation is necessary to get through a stressful experience. However, as time goes on and we get some distance, these adaptations are no longer necessary.

I believe in a growth model of psychotherapy. I adopt a humanistic perspective that favors personal acceptance and understanding. I think that there are many ways to be in this world and one particular way is not right for everyone. I have found that gaining attunement with our authentic selves through the exploration of thoughts, feelings, and behaviors can significantly our satisfaction with our lives. In addition, I think that exploring existential concerns connected with freedom, meaning, relatedness, and death is often beneficial in developing our path. Finally, I favor emotional & cognitive flexibility, compassion, and self-compassion.

I work with thoughts, emotions and behaviors to help you achieve your goals. In session we may work with your feelings about the past, present, or future. We may also work with your thoughts about past, present or future as well. Learning skills such as coping, assertiveness, self-limiting patterns (for example) may be used to help achieve our goals. Role-play techniques may be used to process thoughts, emotions, behaviors and to practice new ways of responding. I also use hypnotherapy to assist in achieving goals. In addition, eye movements, tapping or tones may be used to help work through painful events in the past, to help develop better resources or to work through anxieties or triggers in the future. Cognitive-stimulation techniques may also be used to assist with thinking and memory.

I work with couples and families. I may teach parenting skills, better communication skills and conflict management skills in order to help achieve goals. In addition, I work with couples and families to identify negative patterns of communication and to work through them to foster a more secure environment.

I believe that building on strengths of all people is important and so we may focus on strength building, meaning making and building resilience in our time together.

I am very open to feedback and if at anytime you would like to know more about a particular technique that we are using or about a line if questioning please feel free to let me know. If you are ever uncomfortable with a therapeutic process please let me know and we discuss alternate options.

My Education, Training and Experience I received a Bachelor of Arts with Distinction from The University of Washington in 1999 in Speech Communication. I completed a Masters of Arts in Counseling Psychology from Walla Walla University in 2013. I have been a registered Hypnotherapist from the State of Washington since 2012. I received a clinical hypnotherapist certification in 2013. I have received training in: emotion-focused therapy for individuals, emotion-focused therapy for couples, eye movement desensitization reprocessing therapy in 2013 basic training, advance training in eye movement desensitization reprocessing therapy in dyadic resourcing in 2015 & completed a certification as an anger management treatment professional in 2015. I am a member of the American Counselors Association, the EMDR International association and PSI CHI (the International Honor Society in Psychology). I am currently a doctoral student at Oregon State University in their Counseling (counselor education & supervision) program.

During my graduate training I completed a clinical practicum and internship per program requirements. I have been in private practice since 2013 treating individuals, couples & families.

Client's Course of Treatment If you decide to continue treatment beyond an initial assessment, we will develop an individualized treatment plan with you. This plan will include what is known at the time about your course of treatment and will be amended as appropriate during our work together.

Disclosure statement Page � of �2 2Confidentiality

As a Licensed Mental Health Counselor, I may engage in consultation either in groups or individually with other professionals about your case (e.g. other counselors, psychologists, etc). Limited identifying information will be shared and names may be changed to hide your identity. In addition, I share an office with Dr. Richard Ostrom. In the shared office environment data may seen by other practitioners in the office. In addition, you may encounter other clients who are there to either see myself or Richard Ostrom. You are free to engage in conversation with them or not.

Billing, Fee and Financial Information Your fee will be discussed and written down on the Service Agreement. Procedures regarding additional charges and charges for cancellation will be discussed during the first session as part of the Service Agreement.

Notice to Clients As required under Washington law, therapists practicing counseling for a fee must be registered or licensed with the Department of Health for the protection of the public health and safety. Registration or licensure of an individual with the Department of Health does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment. It is every client's right to refuse or discontinue treatment at any time. It is the responsibility of clients to choose the provider and treatment modality which best suits their needs and purposes.

In addition, licensed or registered therapists are required to inform clients of the purpose of the Counselor Credentialing Act (the law regulating counselors). The purpose of the Counselor Credentialing Act is (A) to provide protection for public health and safety; and (B) to empower the citizens of the state of Washington by providing a complaint process against those therapists who would commit acts of unprofessional conduct. Clients of licensed or registered therapists in the State of Washington may file a complaint with the Department of Health at any time they believe a therapist has demonstrated unprofessional conduct. To obtain a list of actions considered to be "unprofessional conduct,” or to file a complaint, contact the Department of Health, Business and Professional Administration, P.O. Box 9012, Olympia, WA 98504-8001, (360) 236-4700.

By my signature below I acknowledge that I received a copy of the Notice of Privacy Practices and Required Disclosure for Christopher McBride, MA, LMHC and understand the information provided.

Signature of client (or personal representative) Date

Signature of client (or personal representative) Date

Signature of Therapist Date

If a personal representative on behalf of the client signs this acknowledgment, complete the following: Personal Representative’s Name:

Relationship to Client:

This form will be retained in your medical record.

Psychotherapy Risks & Benefits

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the counselor and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. There are no guarantees in the psychotherapy process. Since therapy often involves discussing and performing exercises or techniques around unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Unpleasant memories may come up as well as somatic complaints such as aches and pains in therapy.

Should you undergo Eye Movement Desensitization Reprocessing Therapy (EMDR) you may experience intense sensations and emotions surround re-experiencing of a traumatic event. Effects may last throughout the week as you may continue to process. EMDR stimulates movement of eyes in order to process traumatic memories. I use a use a light-bar which incorporates lights, tones and buzzes to assist with the eye movements. There is a chance that a EMDR with a light-bar may induce a seizer from those people who have Epilepsy. While the risk is small it is important to be made aware of it. Reprocessing a memory may bring up associated memories. The is normal and those memories will also be reprocessed. During the EMDR, the client may experience physical sensations and retrieve images, emotions and sounds associated with the memory. Reprocessing of the memory normally continues after the end of the formal therapy session. Other memories, flashbacks, feelings and sensations may occur. The client may have dreams associated with the memory. Frequently the brain is able to process these additional memories without help, but arrangements for assistance will be made in a timely manner if the client is unable to cope. Reprocessing traumatic memories can be uncomfortable as with any other therapeutic approach.

Should you undergo hypnotherapy services, you may experience intense emotions, remembering painful content in your past or other unpleasant emotions.

Individuals in committed relationships may notice changes in their relationships through the process of psychotherapy. Partners or significant others may have strong reactions to new ways of being that emerge. Sometimes, relationships can even end as the client changes throughout the process.

Psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy.

Some clients may require specialized treatment outside of my scope of practice. Clients may struggle with personality disorder, require more intensive treatment or encounter a condition that I have not been adequately trained to treat. Those clients may be referred to other professionals with the appropriate expertise.

You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. I/we have read, understand and agree that there are risks and benefits to psycho-therapeutic treatment. I/we consent to treatment by Christopher McBride, MA, LMHC.

Print your name here: ______________________________

Client Representative Signature (18 or younger) Date

Client’s Signature Date

Therapist’s Signature Date

Service AgreementChristopher McBride, MA, LMHC provide professional therapy for individuals, couples and families. Please read this Service Agreement carefully so you will understand my policies and procedures.

Fees My fee appointments is $_______ and _______ for the intake session (see rate sheet). By signing this agreement, you agree to pay for all services at this rate for all services provided to you. I reserve the right to change my fees.

Payments Payment is due at the time of service. I can accept cash, check or traditional credit/debit cards (e.g Visa, Mastercard, etc). A $2.00 convenience fee is charged for using debit/credit cards. Checks are preferred. If a check is returned because of insufficient funds, you will be charged $35.00 handling fee.

Appointments You and I will set your appointment time. Once established, your appointment is reserved just for you. 24 hour notice is required to reschedule an appointment. A missed or cancelled appointment will be charged at $_50.00___. Please note: insurance does not pay for missed appointments. You will be charged for any additional services you request of me outside of your appointment time. Any time spent testifying in court will be charged at $_400.00 per hour__ including travel time.

Psychotherapy takes your time and commitment. Thus your attendance is critical. Clients missing 2 or more appointments via late reschedule or no-show in a 10 session period will be terminated from the practice. Clients rescheduling more than 2 times in a 10 session period will be terminated from the practice.

Other Notice I do not make recommendation on work or other duty fitness at this time. Those recommendations should be directed to your physician.

Insurance Your insurance may cover a part of the cost of therapy. If you wish to use your insurance, I will bill your insurance company directly. If I am not in-network with your insurance company, you will be responsible for any difference between what I charge and what your insurance company pays for the service. Please complete the Insurance Information Form. Unpaid balances will incur a 5% per month late fee. Balances over 90 days old may be sent to collections for payment. The collection agency used will be NCMI or like agency.

Confidentiality No information about you is released by me to anyone without your written permission, except as required by law. However, as a Licensed Mental Health Counselor, I may involve other practitioners in consultation. Identifying information will be limited and information will only be shared with other professionals bound by confidentiality. I belong to a Emotion-focused Couples therapy supervision group & EMDR supervision group. In these groups I may divulge case details, names are changed to protect identities. If you have questions about my participation or privacy, please do not hesitate to let me know. In addition, I am required by law to report suspected child abuse (regardless of when it occurred), elder abuse, and clear and concrete evidence of planned acts of violence. I am also required to intervene (and may break confidence) when a client is a danger to self or others. See my Notice of Privacy Practices and Washington Required Disclosure Form for additional details.

Written Records I maintain written files about your service for five (5) years. You have the right to review your file. If so desired, please arrange such a review with me.

Grievance If you have any concerns or complaints about your therapy, address the issue directly with me. If an event has occurred with me that violates the statues of my licensure, you may contact the Washington State Dept. of Health (360) 236-4700.

I/We, the undersigned, certify that I have read and understand my rights and responsibilities as outlined in this document. I understand that if I leave therapy with an unpaid balance, I will make every effort to collect these debts. Any attorney fees or costs resulting from my collection efforts will be an additional charge to my balance owing. I understand my obligations under this agreement, and fully agree to pay for my service at my established rate. I do hereby request and consent to treatment by Christopher McBride, MA, LMHC. I will participate in the development of a treatment plan that best addresses my needs or situation. I understand that nothing in this Service Agreement shall be interpreted to limit or modify my rights and obligations under the State required Disclosure Form or my Notice of Privacy Practices.

Child Consent I/We the undersigned parents (or legal guardians) of , do hereby request and consent to the treatment of our child by Christopher McBride, MA, LMHC.

Client’s Signature Date

Client’s Signature Date

Therapist’s Signature Date