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NEW CLIENT INFORMATION

Name:*
Address:*
Birthdate:*
Phone Number:*
Alternate Phone:*
Occupation:*
Gender:*
Referred by:
Relationship Status:*
Spouse's Name:
Spouse's Date of Birth:
Children's Name(s)/Ages:
Others living in the household:
Issues that brought you into counseling:*
Current Medications:

If a minor, your parent must sign: (I) (We), the undersigned parent(s) or legal guardians do hereby give (my) (our) consent for the provision of outpatient counseling services by Center for New Directions. This authorization shall remain in effect until revoked in writing by the undersigned.

Parent/Guardian Signature:*
Date:*
I acknowledge that Center for New Directions has informed me that I can access all New Client Information forms from their website at Centerfornew.com. These forms include:
1. Client Information Form
2. Counseling Center Agreement for Treatment
3. Notice of Patient Information Practices and
4. Informed Consent of Theoretical Orientation.
My signature on the Client Information Form is my written confirmation that I have been informed of access to these documents online. I also understand that I will be billed a $75 fee if I do not give AT LEAST 24 HOURS notice of cancellation of my appointment, or if I do not show up for my appointment.
Signature:*
Date: *
I would like to receive newsletters from The Center:
I authorization CFND to thank the referral source:

INSURANCE VERIFICATION

Insurance Company:*
Primary Subscriber:*
Primary Subscriber - Date of Birth:*
Subscriber Number*
Policy Number:*
Group Number:*
Insurance Phone:*
Do you have secondary insurance?

NOTICE OF PATIENT INFORMATION PRACTICES

This notice describes how medical information about you may be used or disclosed and how you may access it.

OUR LEGAL DUTY
Center for New Directions, referenced here as CFND, is required by law to protect the privacy of your personal health information, provide this notice about our information practices, and follow the information practices that are describes herein.

USES AND DISCLOSURES OF HEALTH INFORMATION
CFND uses your personal health information primarily for treatment, obtaining payment for treatment, conduction internal administrative activities, and evaluating the quality of care that we provide. For example CFND may use your personal health information to contact you to provide appointment reminders, or information about treatment alternative or other health related benefits that could be of interest to you. CFND may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We also provide information when required by law.
CFND may change it's policy at any time. When changes are made, a new Notice of Information Practices will be posted in the waiting room and client areas and will be provided on your next visit. You may also request an updated copy at any time.

PATIENT'S INDIVIDUAL RIGHTS 
You may have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment, or other related administrative purposes.
You may also request in writing we do not use or disclose your personal health information for treatment, payment, or administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. CFND will consider all such requests on a case by case basis, but we are not legally required to accept them.

CONCERNS AND COMPLAINTS
If you are concerned that CFND may have violated your privacy rights or if you disagree with decisions we have made regarding access of disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send a written complaint to the US Department of Health and Human Services.

Center for New Directions
23201 Mill Creek Dr. #220, Laguna Hills, CA 92653

My signature on the Client Information Form is my release for this Notice of Information document. I am indicating I have read and fully understand the Notice of Information Practices for the Center for New Directions. I understand these practices may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payments, evaluating the quality of services provided, and any administrative operations related to treatment or payment. I understand I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice. I also understand that Center for New Directions will consider requests for restriction on a case by case basis, but does not have to agree to requests for restrictions.

I hereby consent to the use and disclosure of my personal health information for purposes as noted in Center for New Direction's Notice of Information Practices. I understand that I retain the right to revoke this consent by notifying the practice in writing at any time.

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I have read and accept this information*

INFORMED CONSENT OF THEORETICAL ORIENTATION 

Psychology is a method of treating emotional problems by means of a supportive working relationship between the therapist and the patient. In the sanctuary of the therapist's office, the client is encouraged to feel comfortable while discussing their problems and conflicts, and optimistic that they are able to be helped. The therapist may interpret the problems and suggest various ways to cope with them. 

There are dozens of different types of therapy. Basically, however, there are two categories, Psychodynamic Therapies and Behavioral Therapies. 

Psychodynamic therapy -  Designed to help a client better understand the psychological forces which motivate their actions, with the goal that these insights reveal possibilities for change. 

Behavior therapy - Designed to deal with inner feelings and motivations and use specific techniques to chance specific behavioral symptoms. 

Multimodal therapy is an open system that encourages technical eclecticism by utilizing different techniques from various therapies to achieve the client's goal in therapy. 

Psychotherapy cannot change the world around you. Therapy sessions will not eliminate job stress or financial problems, or change the personality of a difficult spouse. What it can do however, is help a client learn to cope more effectively with their environment, evaluate their priorities and responses to stress, and understand and accept themselves as they are. 

In practice, psychotherapy involves a combination of self-exploration by the client and supportive-directive work from the therapist. Therapy may last for only a few sessions, dealing with a specific problem, or it may be long-term and open-ended. Psychotherapy is usually a combination of discussion, explanation, relaxation, exploration, and support. In attempts to make connections between the client's internal experiences and their responses to life events, psychotherapy views problems in the context of the whole person. 

Psychotherapy can provide a safe place for a client to discover and tell themselves the truth. It provides a unique responsibility for the patient to re-expereince their personal history, to see it in a new way, and to make connections between the past and present conflicts that illuminate their situation and, hopefully, enable them to change. 

The therapist acts as a guide as the client explores their inner life. Together, the examine the client's ideals, expectations, hopes, and desires, as well as their feelings of guilt, shame, doubt, or despair. The therapist aims to create an environment of safety so the client can unfold their authentic self without fear or judgement or the pressure to conform or please. 

The goal of psychotherapy is to help a client experience life more deeply, enjoy more satisfying relationships, resolve painful conflicts, and better integrate all the parts of their personality. Perhaps the greatest potential gift of psychotherapy is its ability to provide the client with the essential freedom to change and continue to grow in relationships. 

I have read this Informed Consent completely and have raised any questions with my therapist. I have received full and satisfactory responses and agree to the provisions freely and without reservation. 

I understand that my therapist is responsible for maintaining all professional standards set forth in the ethical principles of the Behavioral Board of Science and the Laws of the State of California covering the practice of professional psychology and that they are liable for infractions of those standards. 

My signature on the Client Information Form is my release for this Informed Consent Document. 

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I have read and accept this information.*

COUNSELING CENTER AGREEMENT FOR TREATMENT

APPOINTMENTS - Appointments are to be made in advance. If you are unable to keep your appointment, you must notify your therapist at least 24-hours in advance. If the appointment is not kept or is cancelled without proper notice, you will be charged. 

DURATION - Counseling sessions are 45-50 minutes. 

CONFIDENTIALITY - Confidentiality will be maintained so you will be free to discuss your concerns openly. Therapists are required by law to break confidentiality in certain specific circumstances, such as elder or child abuse, if there is imminent danger to the client or others, or if the client should bring any type of legal action against the therapist, Center for New Directions. 

FEES - Payment of the agreed upon fee is due and payable at the time of the visit. 

EMERGENCIES - If there is an emergency, contact your therapist by calling the 949-463-5323 or 888-795-4337 and the extension given to you by your therapist. You may also leave a message on the general extension 220. In the event of a life-threatening situation, first call the police and/or paramedics by calling 911. 

REFERRAL OF CLIENT - The therapist, Center for New Directions, and the supervisor, reserve the right to refer the client to another therapist, by giving the name of three other therapists to the client for referral. 

THERAPIST - It is understood by all those seeking services at Center for New Directions this is a teaching facility, which trains people to be psychotherapists. Your therapist may be unlicensed but under the supervision of a licensed therapist. 

AGREEMENT - The fee agreed upon for counseling is
Therapist Name
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I have read and accept the Agreement for Treatment*