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Please realize that our ability to accommodate new counseling clients fluctuates. Indeed, you may find yourself having to wait a week or more before we contact you. You can always email us at office@drscottsparrow.com or call 956-309-3730 after completing this form.

Regardless, completing this intake form does not assure you of receiving services from us. If you do not hear from us before you need to see a counselor, you should call 911, or go to the nearest emergency room if you are in crisis.

There are four sections to this Intake form: Personal Information, Symptom Checklist, Informed Consent, and Telehealth Agreement. Please complete all items to qualify for services.

Personal Information Section

Name of Client (Please include parent or legal guardian's name in parentheses if client is a minor. That person must complete the form for the client.)

Address, City, State, & Zip

Email Address

Phone #

Date of Birth

Gender

In case of emergencies--Please contact: Name and phone number, please

Are you currently seeing a mental health professional?

Yes
No

Are you currently taking medication for a mental health issue? If so, what medication(s)?

In a few words, can you tell us why you are seeking services at this time, and what you would like to accomplish?

Insurance Company (if applicable)

Insurance Policy Holder/Date of Birth

Insurance Policy Number

Do you have a preference for a counselor (for individual, couples or family)? Please see our website for a list of counselors, and include no more than three in order of preference.

Informed Consent Section

Confidentiality and its Exceptions

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.

Also, if your counselor is an LPC-Associate under Dr. Sparrow's state-mandated supervision, he/she will need to review your counselor's work in order to insure the highest quality counseling service.

I have read this section, and agree.

Yes
No

Emergency Contact

In the event of an emergency, you have my permission to contact:

Conditional Provision of Services

Dr. Sparrow and our associates require an initial intake appointment/interview to determine if we can address your counseling needs. Based on the results of the intake interview, we will determine if we can proceed with offering you services. Thus, the scheduling of an intake interview does not guarantee that he, or any of our associates, will be able to assure you a continuation of services. If we cannot work with you, we will nonetheless provide you with referrals to other providers, if you so desire.

I have read this section, and agree.

Yes
No

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 at that point.

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.

If you miss two appointments in a row without notice, we may no longer provide services without reapplication. We will provide you a referral upon request.

I have read this section and agree.

Yes
No

Scheduling of Appointments

Once you filled out this Intake Form, and have been assigned a counselor, he or she will contact you to arrange your first appointment. Please notify your counselor if you are unable to attend any scheduled appointment. Please give your counselor 24 hours notice, whenever possible, so he/she can schedule another client in your place.

I have read this section and agree

Yes
No,

Paying for Appointments

Payment is due prior to the time of services. We have a payment portal on our website at https://www.riograndevalleycounselingservices.com/page/index.html to make payment as easy as possible.

If you have insurance, and we have agreed to accept it, we will bill for services rendered to you. However, you are responsible for paying any amounts not covered by your insurance company.

I have read this section and agree.

Yes
No

Late Cancellation and No Show Policy

If you need to cancel or reschedule your appointment, you will need to notify us within 24 hours of your scheduled appointment. Otherwise, you will be charged $80.

I have read this section and agree.

Yes
No

Emergencies

If you have an urgent issue, please call 956-309-3730, and email us at office@drscottsparrow.com and gscotspar@gmail.com. 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.

Yes
No

Complaints

If you ever have a complaint about your counselor's services, please contact Dr. Gregory Sparrow/your counselor at 956-309-3730 and leave a message if we do not pick up. If we cannot satisfactorily address your concern, 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.

Yes
No

Supervision of Your Counselor

If your counselor is not fully licensed as an LPC, but rather licensed as a LPC-Associate, he/she will be receiving supervision from Dr. Gregory Sparrow, and will often discuss his/her work with Dr. Sparrow. This supervision is necessary in order to responsibly provide counseling services.

I have read this section and agree.

Yes
No

Symptom Checklist
Instructions: The questions below ask about things that might have bothered you. Your responses will help us understand the range and severity of your symptoms. 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.

Little interest or pleasure in doing things?

Not at all or Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Feeling down, depressed, or hopeless?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Feeling more irritated, grouchy, or angry than usual?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Sleeping less than usual, but still have a lot of energy?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

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

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Feeling nervous, anxious, frightened, worried, or on edge?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Feeling panic or being frightened?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Avoiding situations that make you anxious?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Feeling that your illnesses are not being taken seriously enough?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Thoughts of actually hurting yourself?

Not at all or Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Hearing things other people couldn't hear, such as voices even no one was around?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Feeling that someone could hear your thoughts, or that you could hear what another persons was thinking?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Problems with sleep that affected your sleep quality over all?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

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

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Unpleasant thoughts, urges, or images that repeatedly enter your mind?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

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

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Not knowing who you are or what you want out of life?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Not feeling close to other people or enjoying your relationships with them?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Drinking at least four drinks of any kind of alcohol in a single day?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

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)]?

Slight--Rare, less than a day or two
Mild--Several days
Moderate--more than half the days
Severe--nearly every day

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. 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 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 are a client of Dr. Sparrow, and you choose not to consent to Telemental health services, Dr. Sparrow may be able to see you in his office. However, his associates only see their clients online, so you will not be able to see one of our Associates if you decline to receive Telehealth services.

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 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 (unless temporarily saved if you approve of videotaping for supervision purposes -- see above). 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.

I have the right to discuss any of this information with my counselor or Dr. Sparrow (if different) in order to have any questions regarding my treatment answered to my satisfaction. My signature indicates that I have read and understood this information and agree to its terms.

Yes, I consent to receiving (or having my minor child receive) counseling via Zoom videoconferencing if necessary, or if so desired.
No, I do not consent to receiving (or having my minor child receive) counseling via Zoom videoconferencing

By writing your name in the text box below, and submitting the form by clicking on the arrow below, you are agreeing to the terms as specified in the above Intake Form.

Before submitting this form, you may wish to print it out. You can print this form out at this point, but you cannot return to it later. We can always provide you with a copy if you should ever want one.