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Dr. Sparrow's DreamStar Counseling and Supervision Services
Supporting Your Courage to Heal and to Grow
Please check the boxes following the statements below. Completing and submitting this form is required before Dr. Sparrow can provide any services.
Your Name
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Your Email
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Phone Number
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Confidentiality. Everything shared with your counselor will remain strictly confidential, with the exception of the following circumstances: *If a client discloses an incident of child abuse that has not been reported to the state authorities, your counselor must report it; *If a client reports an incident of the abuse of an elderly or disabled person, your counselor must report it; *if a client is a danger to himself or herself, or to someone else, your counselor is permitted by state law to inform the appropriate law enforcement agency. *If your counselor's records and notes are subpoenaed, he or she may be required to submit them. *If you are in a counseling group, the counselor cannot guarantee that confidentiality will be observed by the other members. Every effort will be made to elicit a deep commitment to confidentiality among the members, but ultimately the counselor cannot assure it. I have read this section, and agree.
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Insurance and Diagnoses. If you use insurance, your carrier may require periodic treatment reports that will be evaluated by a case manager(s). While these reports are unavailable to others, they can be subpoenaed. Also, I will need to assign a diagnosis that will become part of your insurance and case record. The diagnosis may change as I obtain additional information over the course of my work with you. I am happy to discuss the diagnosis that I believe is appropriate, and you have every right to inquire about it at any time. I have read this section and agree.
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The Benefits and Risks of Counseling. Individual Therapy. While counseling may help you resolve immediate and longstanding problems, it is also important to acknowledge that counseling can stir up feelings and memories that can prove upsetting to you. Before beginning this process, it is important to ask yourself if you’re ready to embark on a meaningful journey that can, at times, upset you and challenge you. Relationship Therapy. If I counsel you one-on-one, you and you alone are my client. Consequently, I strive to support your autonomy and self-determination, and endeavor to assist you in coming up with solutions for yourself. Because the focus in on you, if you are in a relationship and the relationship is a significant source of stress in your life, individual counseling may support your individual goals at the expense of the relationship. Therefore, if your primary goal is to improve and preserve the relationship, I recommend that you choose conjoint or marital therapy, rather than individual therapy. If you partner is unwilling to participate, it’s important for you to let him or her know that individual therapy alone may not help the relationship, even though I always endeavor to keep the focus on my clients, and to avoid making statements about people I do not know, and who are not my clients
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Conditional Provision of Services. Dr. Sparrow conducts an initial intake interview to determine if he can address your counseling needs. Based on the results of the intake interview, he will determine if he can proceed with offering you services. If not, he will endeavor to refer you to a therapist or service that can assist you. Thus, the scheduling of an intake interview does not guarantee a continuation of services. I have read this section, and agree.
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Termination of Services. We are committed to providing services to you only as long as it is helpful to you. Regardless, you are free to terminate services at any time. Your counselor will endeavor to work with you to find another therapist if you still need counseling upon termination. Similarly, your counselor may, for various reasons, need to end his or her work with you. In that case, and if you would want to continue counseling, we would endeavor to provide you with another counselor, or with a referral. I have read this section and agree.
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Making Appointments. You can make appointments by going to my website at www.drscottsparrow.com, and clicking on the online calendar. Once you schedule an appointment, I will be notified via email, and will make contact with you. Or you may call me (956) 309-3730 to schedule or reschedule appointments. If you get my voicemail, please leave clear details about when you want me to call, and whether calling your home or office number is something you would like us to avoid doing for privacy reasons. Either Julie (office manager) or I will return your call.
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Cancellation of Appointments. Late-notice cancellations and cancellations without notice are costly, so I request 24 hours of notice for cancellation, in order to have time to fill the hour with another client. Our online appointment calendar sends out reminders 24 hours in advance of your appointments. Thank you for respecting this request. For cancellations without notice, I have established the following policy: You must agree to pay $50 for any cancellation without notice at the time of your next appointment.
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Emergencies. If you have an urgent issue, please call 956-309-3730, and email us at support@onlinecounselinggroups.net. If you do not receive a response immediately, you will need to call 911 or go to the nearest Emergency Room. I have read this section and agree.
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Complaints. If you ever have a complaint about your counselor's services, please contact Dr. Gregory Sparrow at support@onlinecounselinggroups.net, or call 956-309-3730 and leave a message if we do not pick up. If we do not satisfactorily address your consent, we encourage you to contact the Complaints Management and Investigative Section, P.O. Box 141369, Austin, TX 78714-1369, or call 1-800-942-5540. I have read this section and agree.
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Billing. If you have insurance, we will submit claims on your behalf, and it is our responsibility to do so if Dr. Sparrow is in-network with your insurance company. We will obtain information regarding the amount that you are supposed to pay, but we cannot guarantee the accuracy of this estimate. Ultimatley, you are responsible researching your coverage benefits, and will be responsible for any part of Dr. Sparrow's fee not paid by your insurance company.
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Telehealth Consent Section. INFORMATION ABOUT TELEHEALTH What are Telemental health services and when are they used? Telemental health services are used when mental health staff cannot be physically present with you to evaluate your mental health needs. Mental health staff may be present at another location and available to serve you through audio/visual technology. Telemental health services use a video camera and computer to send both voice and personal images (pictures) between you and mental health staff so not only can you talk to each other, but you can also see each other. This allows mental health staff to make a better evaluation of your needs. How do Telemental health services work? You will be in a private room by yourself with necessary computer and video camera equipment. Your counselor will also be in a private room but at another location with the same type of equipment. When the session is ready to begin, your counselor will start the computer and camera so that you and he/she can see each other and talk together. When the session is over, the counselor will end the meeting. How is it different than a regular session with mental health staff? Other than you and your counselor not being in a room together, there is very little difference in the session. The counselor will ask and document clinical information that you share with him/her, document the service that is provided, and ensure that documentation is included in your clinical record for future reference. What will I need to receive Telemental Health services? You will need to download the Zoom application at zoom.us to use this platform. Zoom is available on all devices: PC, Mac, IOS and Android. You also need to have a broadband Internet connection or a smart phone access with a good cellular connection at home or at the location deemed appropriately confidential for services. In the event of technology failure, you will need to utilize phone services to inform your student counselor of the technology failure. If the video meeting cannot be held, you and your counselor may opt to connect via your phone connection. What happens if I choose not to consent to Telemental health services? If you choose not to consent to Telemental health services, we will only be able to see you in person. If public health concerns prevent us from conducting office visits, we be unable to provide you with convenient and readily available services and your services will be rescheduled for a later date if face-to-face services can be conducted safely. CONSENT FOR TELEMENTAL HEALTH SERVICES I hereby consent to engaging in telehealth counseling via Zoom as part of my counseling services. I understand that “telehealth” allows my counselor to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. Technology: I understand I will need the Zoom application at zoom.us to use this platform, a broadband Internet connection or a smart phone device with a good cellular connection, and a remote location appropriate for services. Also, in the event of technology failure, I am responsible for contacting my counselor via phone to inform them of the technology failure. I understand I have the following rights under this agreement: 1. I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. I understand that my counselor guarantees confidentiality at his/her location and I am responsible to find a remote location that is reasonably free of distractions and interruption for my sessions. Any information disclosed by me during my therapy, therefore, is generally confidential. 2. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my student counselor may be required to break confidentiality to prevent the threatened danger and immediately notify their faculty supervisor. 3. There is no permanent video or voice recording kept of the Telemental health service’s session. I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my prior written consent. 4. I further understand that there are risks unique to Telehealth, including but not limited to, the possibility that sessions or other communication by my counselor to others regarding my treatment could be disrupted or distorted by technical failures, or could be interrupted, or could be accessed by unauthorized persons. 5. I have the option to withhold consent or to withdraw this consent at any time, including any time during a session, without affecting the right to future care. I have the right to discuss any of this information with my counselor to have any questions regarding my treatment answered to my satisfaction. I have read and agree to the above terms. INFORMATION ABOUT TELEHEALTH What are Telemental health services and when are they used? Telemental health services are used when mental health staff cannot be physically present with you to evaluate your mental health needs. Mental health staff may be present at another location and available to serve you through audio/visual technology. Telemental health services use a video camera and computer to send both voice and personal images (pictures) between you and mental health staff so not only can you talk to each other, but you can also see each other. This allows mental health staff to make a better evaluation of your needs. How do Telemental health services work? You will be in a private room by yourself with necessary computer and video camera equipment. The mental health staff will also be in a private room but at another location with the same type of equipment. When the session is ready to begin, a counselor will start the computer and camera so that you and he/she can see each other and talk together. When the session is over, the counselor will end the meeting.. How is it different than a regular session with mental health staff? Other than you and mental health staff not being in a room together, there is very little difference in the session. The counselor will ask and document clinical information that you share with him/her, document the service that is provided, and ensure that documentation is included in your clinical record for future reference. What will I need to receive Telemental Health services? You will need to download the Zoom application at zoom.us to use this platform. Zoom is available on all devices: PC, Mac, IOS and Android. You also need to have a broadband Internet connection or a smart phone access with a good cellular connection at home or at the location deemed appropriately confidential for services. In the event of technology failure, you will need to utilize phone services to inform your student counselor of the technology failure. If the video meeting cannot be held, you and your counselor may opt to connect via your phone connection. What happens if I choose not to consent to Telemental health services? If you choose not to consent to Telemental health services, we will be unable to provide you with convenient and readily available services and your services will be rescheduled for a later date and/or a different site. CONSENT FOR TELEMENTAL HEALTH SERVICES I hereby consent to engaging in telehealth counseling via Zoom as part of my counseling services. I understand that “telehealth” allows my student counselor to diagnose, consult, treat and educate using interactive audio, video or data communication regarding my treatment. Technology: I understand I will need the Zoom application at zoom.us to use this platform, a broadband Internet connection or a smart phone device with a good cellular connection, and a remote location appropriate for services. Also, in the event of technology failure, I am responsible for contacting my student counselor via phone to inform them of the technology failure. I am also aware that a supervisor may join the telemental health session to observe from time to time, as part of my counselor’s training, and to ensure the highest quality services. I understand I have the following rights under this agreement: 1. I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical information for in-person psychotherapy. I understand that my student counselor guarantees confidentiality at his/her location and I am responsible to find a remote location that is reasonably free of distractions and interruption for my sessions. Any information disclosed by me during my therapy, therefore, is generally confidential. 2. There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my student counselor may be required to break confidentiality to prevent the threatened danger and immediately notify their faculty supervisor. 3. There is no permanent video or voice recording kept of the Telemental health service’s session, any such information will be used for the purpose of overseeing services to ensure best quality care and destroyed in a timely manner. I understand that the dissemination of any personally identifiable images or information from the Telehealth interaction to any other entities shall not occur without my prior written consent. 4. I further understand that there are risks unique to Telehealth, including but not limited to, the possibility that sessions or other communication by my student counselor to others regarding my treatment could be disrupted or distorted by technical failures, or could be interrupted, or could be accessed by unauthorized persons. 5. I have the option to withhold consent or to withdraw this consent at any time, including any time during a session, without affecting the right to future care. I have the right to discuss any of this information with my student counselor and their faculty supervisor to have any questions regarding my treatment answered to my satisfaction.
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