Lifehouse Restoration Center "LIGHTING THE WAY TO LIVING WELL"

             Client forms and information

 
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On this page are forms and statements with a description of each and a download link.
If you are unsure how to access these, GO HERE for explanation or ask to have sent by email.

1. Professional Disclosure Statement 
2.
Group Therapy Agreement
3.
Treatment Disclosure Authorization       
4. Professional Release of Information Form
5. Counseling Intake Form (IMPORTANT - all clients MUST fill out and return)
6.
Marriage Contract form
7. Client Social History


  1. Professional Disclosure Statement : This statement is required by the state of Colorado to be provided to all new clients and must be signed and dated and returned to the Counselor. You may download this statement, print it out, sign and return to the Counselor (Susan Anderson) by fax or postal mail (see Contact Us page). You will be provided with a copy upon signature of the Counselor. (MS Word document)

                          left click ==>DOWNLOAD NOW <== left click

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2. Group Therapy Agreement : This is an agreement between you, the client and Susan Anderson, the Counselor. It states the terms and requirements for entrance into Group Therapy. You may download this statement, print it out, sign and return to the Counselor (Susan Anderson) by fax or postal mail (see Contact Us page).  Or, you may download, "sign" it electronically and return to Counselor by email. (MS Word document)

                               
  left click ==>DOWNLOAD NOW <== left click

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3. Treatment Disclosure Authorization : This form is an authorization for your therapist to disclose confidential information concerning you, including medical records, treatment notes, progress notes, evaluations,
and reports or records of other treatment providers concerning you to the specific person you designate. It must have an original signature and be dated and returned to your health care provider.

                         left click ==>DOWNLOAD NOW <== left click

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4. Professional Release of Information Form: This form is used to give permission to use information about you (the client) to Lifehouse Restoration Center (Susan Anderson) for the purposes of research for seminars, articles, books, etc. It allows for release of case histories, client stories and any other personal information provided to LRC in the process of therapy. It does allow for exceptions and stipulations regarding use.

left click ==>DOWNLOAD NOW <== left click

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5. Counseling Intake Form: ALL NEW clients must fill out this form (5 pages) thoroughly and return to the counseling center ASAP. Instructions for return are included at the end of the form. We ask that you provide this personal information and history in this manner so as to save you session charges spent on the Counselor while obtaining the information.

left click ==>DOWNLOAD NOW<== left click

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6. Marriage Contract Form: A contractual agreement between husband and wife to set forth some terms and conditions for their relationship. The purpose is to not only save the marriage but to build a relationship to be much more than it ever has been. Requires agreement and signatures of both parties. Terms may be altered or others added with the approval of the Counselor.

left click ==>DOWNLOAD NOW<== left click

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7. Client Social History: A comprehensive form that includes information about client's early years, family, and home life. Continues with client's own assessment of personality traits, values and emotions. Also includes questions regarding the influence of others on the client's life, questions about spirituality and an opportunity to express goals and aspirations.

left click ==>DOWNLOAD NOW<== left click

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INSTRUCTIONS to download forms:
1. Left click the link above and a pop up box will appear
2. Left click on the "SAVE" button which will bring up windows explorer showing folders and files on your hard drive.
3. Select the location you want to save the file in and save it (You can just save it to your desktop and later open it from there).
4. After saving the file, you may be offered the option of opening it now - if you wish to work with it now then go ahead and open it. If not, close the pop up boxes.
5. When you are ready to fill out the form, go to the saved location and double click on the file to open it in Word. Fill it out and save the newly filled out form.
6. You can now send it by email - just attach the file to your email.
7. Or, you can print out the filled out form and then fax or postal mail it to us.

NOTE: Word documents will open in Internet Explorer if you choose to Open from the pop up. MS Publisher forms will not and you MUST have Publisher in order to open them.

If you have any problems, let us know and we will help - SEND THIS EMAIL

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If you need immediate assistance, please call or
email Susan Anderson
.

 

2004-2015 Lifehouse Restoration Center
All Rights Reserved
phone: 716-567-4079
email: newlifesusan@me.com