Blue Triangle Counseling, PLLC

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Blue Triangle Counseling, PLLC David P. Sumner, LLPC

302 Lafayette Blvd.

Owosso, MI 48867-2017

989 725 8208

PROFESSIONAL DISCLOSURE STATEMENT I have a duty to protect you and others from harm I must keep all details of our counseling relationship, including anything you tell me, in strict confidence, unless I have your expressed permission to inform or consult with someone else. I may consult with colleagues for supervision with the understanding that I will not disclose your name or other identifiable personal information.

This code of confidentiality has only a few exceptions:

1. I must disclose information to a third party (police or Department of Human Services, etc) if I learn of any potential abuse or neglect of a child, elderly or vulnerable person, or if I learn that you are a threat to yourself or any other person.

2. If I receive information confirming you have a disease known to be communicable and fatal, I must disclose this to a third party, who by their relationship with you is at high risk of contracting the disease. Before making the disclosure, I must determine that you have not already informed the third party and have no intention to do so.

3. I will not disclose any information without first consulting my colleagues or other professionals regarding the validity of these exceptions. 4. Should you request that I reveal information about our counseling relationship to others, I will ask you to first sign a release of information form specifying exactly what you wish revealed and to whom. IntroductionPersonal and career counseling is conducted in various ways, depending on the counselor. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship. The information presented here is to help you decide if my services are suitable for your needs at this time. Please discuss any questions or concerns you may have before we begin our session. My Credentials and ExperienceI hold a Master of Arts in Counseling from Spring Arbor University, and a Bachelor of Arts in Family Life Education from the same institution. I am licensed in the state of Michigan as a Limited Licensed Professional Counselor. I am being supervised by Charles Richards, 705 Dayton, Davison, MI 48423. I have over 25 years of experience in Christian education, including incidences of parent-adolescent conflicts, unexpected pregnancies, and divisions in the church.I have a professional membership in the American Association of Christian Counselors, and I am a facilitator of the Blees method of Scenario Role Play Therapy. I have functioned as a Mediator with the Flint, Michigan Mediation Center and a Mentor with the Flint Area Concerned Pastors. I was a Tutor with the Guthrie Literacy Coalition in Guthrie, OK. I am experienced with bipolar personality disorder (in cooperation with a personal physician), relationship conflicts, career difficulties, anxiety, depression, grief, stress/anger management and various issues of people with disabilities.

The Counseling/Consultation Process

People come to counseling because they want something to be different in their lives. They may want to change their personal or family situation, solve a particular problem, or simply bring a healthier balance to their lives. The counseling process can be fun and exciting. It can also, at times, be very challenging, difficult and even painful. However, the goal will always be to bring about some positive change.At our initial meeting, we will assess your current needs and concerns, and decide if we can work together to address them. We will evaluate the results of our work together, and determine the need for additional sessions, termination, or outside referral for further counseling or assistance.Throughout our work together, I will make every reasonable effort to professionally facilitate the resolution of your needs and concerns. Ultimately, you must decide to use what you gain from the counseling process. Your Rights and ResponsibilitiesYou have the right to ask me to explain my reasons for making certain recommendations or for using certain procedures. You also have the right to refuse to follow these recommendations, and/or to terminate the counseling process at any time and for any reason. I have the right and the ethical responsibility to terminate counseling and offer a referral to another counselor if you choose to not follow my recommendations. Either of us may request a final session to discuss the reasons for termination, and decide on an appropriate referral if desired. Please inform me if you are seeing another counselor or health professional during the course of our work together, so that we may provide consistent treatment for you.You have the right to confidentiality as explained in the first section.Our work can only be effective with commitment and continuity. If you must cancel a scheduled appointment, please inform me 24 hours before the appointment.

You will be responsible for payment for any missed or uncancelled appointments, except in the case of a personal emergency. The counselor will determine what a personal emergency is. Please be on time for scheduled sessions, as other clients may have appointments with me immediately following yours. Note that if you are late the session will end on time and you will be responsible for full payment.

Fees for ServiceSliding scale rates and inkind is available on a limited basis, as needed.First introductory/intake sessions (30-120 minutes) are freeRegular Sessions (50 minutes) $80.00Full-time Students $45.00Consultation and Advice by contract Fees are payable at the beginning of each session by check or cash. Make checks payable to David P. Sumner, LLPC, and please have check prepared in advance so that session time can be best utilized. Please sign below indicating that you understand all the information in this document.

Signature: _____________________________ Date:_______

Signature: _____________________________ Date: _______

   Intake Form(All files are held in strict confidence) Client number_____________ Date___________ Counselor______________First Name _______________ MI ______ Last Name____________________Maiden Name ______________________Age ___________________   Date of Birth ________________ Gender        Male      Female
Ethnicity: Asian/Pacific Islander   White        Hispanic         Black       American Indian
Relationship Status:  Single    Married     Engaged      Separated     Divorced        WidowedLocal Address __________________________________________________________City______________________________ State______________Zip Code_______________Local Phone ___________________________________________ May we leave confidential message
Email ________________________________________________ May we leave confidential message
Alternate address or phone number _______________________________________________
_____________________________________________________________________________
Number of hours spent in employment or education __________________________________
Who referred you to Blue Triangle Counseling, PLLC ?      Self     Friend        Family          Employer        Instructor      Healthcare Provider      CounselorName of Person referring _______________________________________________________
Blue Triangle Counseling, PLLC
                                                                                                                      David
302 Lafayette Blvd
       Owosso, MI 48867-2017                                                                                                    989 725 8208 Please read following questions and mark those to which you would answer “Yes.”

           Have you previously been involved in counseling?           Do you currently use alcohol or non-prescription drugs?          Is there a history of mental health problems in your family?          Have you ever been physically abused?          Have you ever been emotionally abused?          Are your concerns interfering with your job or academic performance?          Have you ever attempted suicide?          Have you ever been hospitalized for mental health reasons?          Is there a history of alcohol or drug problems in your family?          Have you ever been in legal trouble?          Have you ever been sexually assaulted or abused?          Are you taking any prescription medications?          Are your concerns interfering with your ability to remain in your current employment?Please describe the concerns you would like to discuss with the counselor  How long has this problem persisted? Under what conditions do your problems get worse? better?  Counselor NotesBlue Triangle Counseling, PLLC                                David P. Sumner, LLPC                                                                                                    302 Lafayette Blvd.                                                                                                    Owosso, MI 48867-2017                                                                                                    989 725 8208 Please mark all of the following that apply:
Feelings:__Helplessness    __Anxious __Depressed__Out of Control __Shameful   __Afraid__Angry __Numb __Guity __Relaxed__Hopeless __Happy __Lonely
__Excited__Sad __Hopeful __Stressed __Unhappy__Inferiority Feeling __Mood Shifts__ Other__________________________
HIPAA Privacy Rights Request Form Client Information
                                                                                                _________________________
                                                                                                Date
__________________________________________________         _________________________
Name (Last, first, middle initial)                                                  Social Security # or Patient ID
___________________________________        ___________________      _____   ____________
Street address                                               City                                 State    ZIP Code
__________________________      _____________________     ___________________________
Primary phone number                  Other phone number            E-mail address
Type of Request
c   Access/copy                                c Amendment                                 c Restrictionc   Confidential communication          c    Accounting of disclosures                  c         Complaint
Please describe nature of action requested (type of information requested; nature of amendment, restriction, alternative communication, or complaint, etc.) in detail.
[Note: If this is an alternative communications request, please list alternative location/address for receiving medical information below.]
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list staff members that were contacted regarding this matter:
______________________    _____________    _______________________    ____________
Name                                     Date                    Name                                      Date

Signature __________________________________________       Date ____________________
For Administrative Use Only:                                                Date received _______________
Action taken ___________________________________________________________________
___________________________________________________________        Date _____________
Action taken ___________________________________________________________________
___________________________________________________________        Date _____________

Counselor signature______________________________________               Date _____________

Thoughts__Confused __Racing __Unintelligent__ Obsessive __Worthless __Distracted__ Unmotivated __Disorganized __Unattractive__ Paranoid __Unlovable __Suicidal __Confident __Sensitive __Worthwhile__Honest __Homicidal__Other_______________________________


HIPAA Privacy Rights Request Form
Client Information
                                                                                                _________________________
                                                                                                Date
__________________________________________________         _________________________
Name (Last, first, middle initial)                                                  Social Security # or Patient ID
___________________________________        ___________________      _____   ____________
Street address                                               City                                 State    ZIP Code
__________________________      _____________________     ___________________________
Primary phone number                  Other phone number            E-mail address
Type of Request
c   Access/copy                                c Amendment                                 c Restrictionc   Confidential communication          c    Accounting of disclosures                  c         Complaint
Please describe nature of action requested (type of information requested; nature of amendment, restriction, alternative communication, or complaint, etc.) in detail.
[Note: If this is an alternative communications request, please list alternative location/address for receiving medical information below.]
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list staff members that were contacted regarding this matter:
______________________    _____________    _______________________    ____________
Name                                     Date                    Name                                      Date

Signature __________________________________________       Date ____________________
For Administrative Use Only:                                                Date received _______________
Action taken ___________________________________________________________________
___________________________________________________________        Date _____________
Action taken ___________________________________________________________________
___________________________________________________________        Date _____________

Counselor signature______________________________________               Date _____________

Physical Symptoms:__Insomnia __Tired __Weight Gain or Loss __Pain __Headaches __Tightness In Chest__Dizziness or Light-headedness __Vomiting __Rapid Heart Beat __Dry mouth __Excessive Sleep__Loss of Memory __Eating Problems __Other_________________________________________
Describe any medical conditions that you have:

Is there anything else you would like us to know about you?

AUTHORIZATION TO RELEASE COUNSELING INFORMATION

Client Name:

Date of Birth:

Previous Name:

Social Security #:

I request and authorize

Release counseling information of the Client named above to:

Name:

Address:

City:

State:

Zip Code:

This request and authorization applies to:

¨ Counseling information relating to the following treatment, condition, or dates:

¨ All Counseling information

¨ Other:

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

¨ Yes ¨ No

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

¨ Yes ¨ No

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Client Signature:

Date Signed:

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

HIPPA Agreement You have the right to Inspect and copy your counseling and therapy information. Under federal law, however, you may not inspect or copy the following: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and counseling and therapy information that is subject to law that prohibits access to counseling and therapy information.You have the right to request a restriction of your counseling and therapy information. This means you may ask us to use or disclose any part of your counseling and therapy information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your counseling and therapy information not to be disclosed to family members or friends who may be involved in your care or for notification purpose as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your counseling and therapy information, your counseling and therapy information will not be restricted. You then have the right to use another Health care Professional. You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us. Upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your counseling and therapy information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your counseling and therapy information. We reserve the right to change the terms of this of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Michigan Department of Community Health if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before February 20, 2010. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to counseling and therapy information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices: Print Name___________________________________ Signature_________________________________Date_________________________________________

302 Lafayette Blvd

Owosso, MI 48867-2017

989 725 8208

HIPAA Privacy Rights Request Form Client Information

_________________________

Date

__________________________________________________ _________________________

Name (Last, first, middle initial) Social Security # or Patient ID

___________________________________ ___________________ _____ ____________

Street address City State ZIP Code

__________________________ _____________________ ___________________________

Primary phone number Other phone number E-mail address

Type of Request

c Access/copy c Amendment c Restrictionc Confidential communication c Accounting of disclosures c Complaint

Please describe nature of action requested (type of information requested; nature of amendment, restriction, alternative communication, or complaint, etc.) in detail.

[Note: If this is an alternative communications request, please list alternative location/address for receiving medical information below.]

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list staff members that were contacted regarding this matter:

__________________________________ ______________________ ____________

Name Date Name Date

Signature __________________________________________ Date ____________________

For Administrative Use Only Date received _______________

Action taken ___________________________________________________________________

___________________________________________________________ Date _____________

Action taken ___________________________________________________________________

___________________________________________________________ Date _____________

Counselor signature______________________________________

Date _____________