Are you currently seeing a mental health professional?
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. 
 
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Emergency 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. 

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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 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.
 
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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.

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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.

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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. 
 
 
 
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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.
 
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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.
 
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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.
 
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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?
Feeling down, depressed, or hopeless?
Feeling more irritated, grouchy, or angry than usual?
Sleeping less than usual, but still have a lot of energy?
Starting lots more projects than usual or doing more risky things than usual?
Feeling nervous, anxious, frightened, worried, or on edge?
Feeling panic or being frightened?
Avoiding situations that make you anxious?


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



Feeling that your illnesses are not being taken seriously enough? 


Thoughts of actually hurting yourself?
Hearing things other people couldn't hear, such as voices even no one was around?
Feeling that someone could hear your thoughts, or that you could hear what another persons was thinking?
Problems with sleep that affected your sleep quality over all?
Problems with memory (e.g. learning new information) or with location (e.g. finding your way home)?
Unpleasant thoughts, urges, or images that repeatedly enter your mind?
Feeling driven to perform certain behaviors or mental acts over and over again?
Not knowing who you are or what you want out of life?
Not feeling close to other people or enjoying your relationships with them?
Drinking at least four drinks of any kind of alcohol in a single day?
Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?

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)]? 

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.