Call Us: 1-512-815-3121

Complete Initial Packet-Streams 2017

Liz Lawrence, MA, LPC-S

Consent Standards and Policies

 

Welcome

Thank you for choosing to share your life with me. I count it a privilege to come alongside you and will serve to merit your trust through the counseling, or discipleship process. If you have any questions about the consent standards and policies, please ask.

Who I Am

The purpose of counseling and the form of coaching I do through counseling is to come alongside those seeking to address problems or break free from relationship hindrances to healthy, fruitful living as disciples transformed by God living as loved people to transform their world. It is my desire to best serve you and I will offer referrals to reputable professionals at any time. The use of the my offices does not dictate anything other than a voluntary use of the facility for counseling at the request of the client and the information and advice given to be provided are suggestions for the benefit of the client to be used at the client’s own personal discretion and implementation.

Confidentiality

All sessions and relationships are held in the strictest confidence. You may choose to have others involved in your counseling process. These individuals and others on a treatment team can be included through a signed release form that is provided by your counselor and kept in your file. As the client, you may request a copy of treatment information in your file and we will grant this request unless we deem it to be clinically inappropriate. Prior approval of release of information may be needed in some cases with a secondary client. I will not knowingly acknowledge any communication with a client without his or her express written permission except in the following circumstances. In the case of #1-4 I am required by law and code of ethics to notify appropriate law, regulatory, and/or medical personnel. 1) If clients threaten to harm themselves, 2) or others; 3) if clients report possible abuse of a child, elderly person, or disabled person in any way; 4) if a judge in a court of law subpoenas a release of information regarding your counseling; 5) if you grant permission for your records to be sent to another professional.

Charges for Services and Payment

Fees will be determined during the initial assessment. Payment is due upon arrival for your session and will be accepted by your counselor. I accept online payments, cash or checks, with counseling in the memo line.

Counseling Choice Fee Scale
Professional Counselor $140/session
Sliding Scale Counseling Varied as agreed using sliding fee scale form.
Group Counseling Varied by groups.

Two ways to complete your packet:

1. You may fill out your information online by answering PART A and PART B below. 
2. Or you can DOWNLOAD a PDF copy of the form by clicking this link, print and fill it out and bring it to your appointment. 

PART A  (online submission)

I will be paying for sessions by:


Insurance

Insurance is not currently accepted but if you bring your insurance forms, professinoal counselors may be able to fill in needed diagnosis for you to file your cliam. Any diagnosis will be in your permanent insurance records.

Further Appointments

Further appointments will not be scheduled until payment is received.

Referrals

Referrals will be provided and you are responsible for contacting and evaluating the referrals.

Appointments and Cancellations

You may schedule your next appointment whle you are in the office or by calling 512-891-1600 ext. 631 for Pastoral and Lay Counselors and ext. 651 for Professional Counselors or your infividual counselor if they have a confidential messaging service. The time of your apointment is reserved for you alone, so please call us directly if you cannot attend. Appointments cancelled fewer than 24 hours in advance are subject to half charge. If you arrive late for your session, we will use the time remaining but you will be charged the full rate. Life-threatening emergencies and sudden illnesses will be considered grounds for waiving charges.

Complaints

We encourage you to bring your concerns directly to us and if you desire, also the the FEFC Senior Pastor so we can immediately address your concerns. Our desire is to protect your process in the counseling with Treams Counseling Center. If you feel we have been unwilling to listen or have behaved unehtically, you may file a complaint against a Licensed Professional Counselor by contacting the Texas State Board: Complaints Management and Investigative Section P. O. Box 141369 Austin, Texas 78714-1369 or 1-800-942-5540 to request the form or obtain information.

Agreement





By typing my name and date in the boxes below I am giving my legal signature attached to this agreement with my full understanding.

FAMILY / HOUSEHOLD INFORMATION

Relational Status:

Select status dates for the following where applicable:

If applicable, please answer the following.


Do you have children? Please list their names and ages.






INDIVIDUAL INFORMATION




Desired Solution



Spiritual or Religious Affiliation











RedArrow01You’ve done a great job completing PART A of your online information packet. Please click the SUBMIT button above and continue immediately to PART B to complete this packet. Thank you!

 

PART B  (online submission)

* indicates required field

_______________________________________________________________________________________________

For PART B, please give us your name, email and phone number again! Thank you!

PHYSICAL HEALTH INFORMATION:
























Check any additional concerns (alphabetized):


















Streams Counseling Center

Notice of Privacy Practices

Our Commitment to you and your privacy

This notice describes how information about you may be used and disclosed and how you can get access to it. HIPPA stands for the Health Insurance Portability and Accountability Act and was passed because of concerns in an age of electronic records. It is important to us you understand our policies and your rights to safeguard your protecetd health ing information (PHI). Some of this information is duplicated on the Standards and Policies.

Uses and Disclosures

We may use or disclose your protected health information (PHI) for treatment, payment, and health care purposes with your consent.

  • PHI: information in your health records that could identify you
  • Treatment: medical or mental health care provided to you by a physician or therapist
  • Payment: to obtain payment for services we provide to you
  • Health Care Operations: include quality assessment, business audits, adminsitrative, case management and care coordination
  • Use: activities within our practice such as examing and analyzing information that identifies you
  • Disclosure: activities outside our practice such as releasing, transferring, or providing access to information about you to other parties

Use of Email

Email is not a preferred type of communication but if you choose to email, your information is not guaranteed to be protected. Your counselor most likely will not respond to any emails until in person within your scheduled session. Emails may contain PHI and email does not meet the necessary security requirements used to protect confidentiality. Email is NOT for emergencies.

Uses and Disclosures Requiring Authorization/Release

We may use or disclose your PHI when your authorization and signed release is obtained for these specific disclosures. Psychotherapy notes have a greater legal protection than your PHI and will not be released without your consent. As a client you may revoke all authorizations at any time, provided each revocation is in writing. You may not revoke authorization if the authorization has already been obtained and acted on or if the authorization was obtained as a condition of obtaini g insurance coverage and the law provides the insurer the right to contest under the policy.

Uses and Disclosures with neither Consent Nor Authorization

We may use or disclose your PHI without your consent or authorization as required by law in the following circumstances:

  • Child abuse: if we have cause to believe a child has been or may be abused, neglected, we are required by law to report it within 48 hours to the proper authorities
  • Elderly or Disabled Person Abuse: if we have cause to believe that an elderly or disabled person has been or may be abused, neglected, or exploited, we are required to report it to the proper authorities
  • Health Oversight: if a complaint is filed agianst us with the State Board of Examiners, they have the authority to subpoena confidential mental health information that is relevant to the complaint
  • Judicial or Administrative Proceedings: if you are involved in a court proceeding and a request is made for the information about your diagnosis and treatment and the records thereof, such information is privileged and will not be released without written authorization. This does not apply when you are being evaluated for a third party or where the evaluation is court ordered.
  • Serious Threat to Health or Safety: if we determine there is a probability of physical injury to yourself or others, or probability of such, we may disclose relevant confidential mental health information to medical or law enforcement personnel.

Clients Rights and Responsibilities

  • You agree to responsibly participate actively in the process of therapy both in sessions and between sessions, and you also agree to be honest with your therapist
  • You agree to arrive on time for sessions and pay for services received
  • You agree to notify your counselor if you become unable to attend sessions and if you do not cancel within less than 24 hours, you agree to possibly pay a half charge for the session
  • You have the right to request restrictions on certain uses and disclosures of protected health information. However we are not required to agree to a requested restriction.
  • You have the right to request and receive confidential communications of PHI by alternative means and at an alternate location (i.e. bills sent to an alternative address).
  • You have the right to inspect a copy of your PHI. Psychotherapy notes that are kept separate from PHI are protected.
  • You have the right to request an amendment of PHI for as long as the PHI is maintained in your record. The request may be denied but the details will be discussed.
  • You generally have the right to request an accounting of disclosures of PHI for which you hav neither provided consent nor authorization.
  • You have the right to obtain a paper copy of this notice.

Therapists Duties

  • We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.
  • We are required by law and state board c ode of ethics to break confidentiality if any of the above listed circumstances occur.
  • We reserve the right to change the privacy policies and practices described in this document after notification.
  • If revisions to policies and procedures occur, you will be notified and provided with a copy.
  • Most therapists at Streams are not providers of insurance but will provide a needed diagnosis code for your to file with your insurance. Any diagnosis will become a part of your permanent record.
  • We will take care to practice within our individual level of competence and licensure.
  • We will discuss the how's and why's of any suggested interventions within the therapy process.
  • We will refer you to other professionals at any times you request.

Complaints

We encourage you to bring your concerns directly to us and if you desire, also to the FEFC Senior Pastor so we can immediately address your concerns. If you feel we have been unwilling to listen or have behaved unethically, you may file a complaint against a Licensed Professional Counselor by contacting the Texas State Board: Complaints Management and Investigative Section P. O. Box 141369 Austin, Texas 78714-1369 or 1-800-942-5540 to request the form or obtain information.

Clients Rights and Responsibilities

I also understand I will sign and date a copy of this Privacy Policies Notice at my first scheduled counseling session.



Living as a healthy whole disciple of Christ
___________________________________________________________

We have been designed by God in His image to be whole people with spiritual, mental, emotional and physical needs. The reality is that a healthy body is impacted by a healthy soul and mind and each of those impact the other. We know that all of who we are is important to God because we see the Scriptures calling us to consider our bodies, thoughts, emotions, wills, actions and meditations. We also know that all of who we are flows out of relationship with God into our relationships with others.

As we go through life our relationship with God changes some and we know it helps to adjust our spiritual disciplines just as it is necessary to adjust our physical or mental activity as our body and mind changes with life seasons. Sometimes our mind, body or soul experiences internal or external suffering. These are trying times for our relationship with God and others as our suffering often impacts how we see God, others and ourselves. We need help to suffer well without over spiritualizing, causing contempt or anything else including increasing depression. Other times when we are not suffering we can live our lives getting to know HIm better so we may truly delight in Him, and more often than not live healthfully as a whole disciple winning others to relationship with Him.

Do you want to be a healthy whole disciple? "Dear Friend, I am praying that all is well with you and that your body is as healthy as your soul is" [3 John 2 NLT].

As you go through this season in your life, consider how you may live as a healthy whole disciple and remember Our Father loves you and rejoices over you now.

1. Soul Health/Spiritual nourishment. "Our souls are healthy to the extent we maintain connection and receptivity to God." -Mindy Caliguire, Willow Creek. "The soul is the engine room of our lives."-Brian Houston, Hillsong Church. Continue to help your soul throughout the season of life:

  • Teach your soul to be quiet. Ps 62:5
  • Educate your soul and preach the truth to yourself. Prov 19:2 You can have lots of degrees or doctorates, but ultimately it is what your soul knows that directs your life.
  • Fill your soul with hope. Heb 6:19
  • Teach your soul to boast and declare God's love. Ps 34:2
  • Teach your soul to be accountable. Accept responsibility and accountability for your choices and invite the Lord to lead you. Ps 119:10; 139:23
  • Teach your soul to lament, grieve or mourn with confidence. Ps 42:130

2. Healthy eating with nutritional supplements. What you eat determines how you feel and sometimes think. So choose your food wisely and consider being tested for food allergies. Eliminate nicotine, caffeine and decrease simple carbohydrates. Vitamins or supplements may be recommended as led by your doctor.

3. Life Rhythm or Rule. A rhythm or rule for life is a simple statement of the regular rhythms we choose in order to partner with God for transformation, they are a brief and realistic scaffold of practices that support your heart's desire to grow in loving God and others. It honors your limits and your God-given longings. The guiding desire might sound like: "Live a sane and holy rhythm that reflects a deep love for God and respect for how he had made me." Allow yourself to find your rhythm or rule that frees and opens you to the will and presence of Christ. (2 sources: Spiritual Disciplines Handbook by Calhoun, p35; and www.emotionallyhealthy.org )

4. Proper hydration. Water is your body's lubricant so make sure you get enough for you and avoid an abundance of substances that cause dehydration like caffeine and alcohol.

5. Restorative sleep. Guard your sleep and plan well to prepare your body for rest; that may mean setting aside time before bed to slow down. Often 7-8 hours of sleep is optimal, but some of us need less or more at certain ages or seasons/times. Sleep is critical for clear thinking, energy, relational connection to others and ability to focus in times with God.

6. Physical movement. Our bodies are made to move, so plan daily exercise and ask your doctor to help you determine healthy options for this season. A general rule is to exercies for 20-30 minutes 5-7 times a week. Do you like to walk, dance run, skip rope....?

7. Social community fun. We are made to be in relationship. Laughter and joy with others have immediate physical, mental and spiritual effects. Telling others about Christ is part of who we are as disciples of Jesus Christ so share you story with others. Also mourning with others, comforting others and allowing them to comfort us leads to blessing. Share life health-fully with trusted others and give of yourself healthfully being aware of your current limits.

 

At First Evangelical Free Church the Care Ministry considers "living as a Healthy Whole Disciple" to be simplified by our tag lines of Community, Worshp and Mission: Join a comunity or small group, worshp as part of a congregation, and serve your larger community on mission bringing others to know the Lord.

In the FEFC Care and Counseling Ministries we have people who would like to offer care to you and also people willing to offer training to equip you to provide care to others. Give us a call or send us an email if we may join you in your current season. 512-891-1600 or care@fefc.org

What's your next step after readhing through Living as a Healthy Whole Disciple?

Medical Tip: This is general information. Before making any health changes, consult your physican.

Information taken from M. Calliguire (Soul Health), Gregory Jantz, Ph.D (Healing the Scars...), Daniel Amen, PhD (Dietary/Lifestyle Issues for a Healthy Brain), D. Ferguson (Discovering Intimacy), Peter Scazzero (Emotionally Healthy Spirituality) and A.A. Calhoun (Spiritual Diciplines: Practices that Transform)

 

Streams Counseling Center at First Evangelical Free Church

Elizabeth Lawrence, M.A., LPC, LPC-S
512-891-1651
Liz.lawrence@fefc.org

I hope this disclosure will provide you with a beginning understand of how I offer counseling and counseling discipleship. Please contact me with your additional questions.

Nature of Counseling and Coaching

I see the nature of counseling adn coaching as a part of the discipleship process including professionals, healthy community and for the purpose of healing for the whole person. Sometimes a need for vision, current mental illness, physicall illness, pain, sadness, aloneness, or an accumulation over time of such brings about a need for an objective professional to offer care, direction and tools. Once professional counseling is complete, you may continue the healing process with your community.

I often work collaboratively with followers of Christ of all ages individually and in groups. Some are in a time of transition and benefit from coaching toward a vision. Some are living with chronic or an acute issue or illness and benefit from clinical Christian counseling. I regularly work with "creatives" (artists of different mediums) who include their art in therapy.

My focus areas are tying together the spiritual, relational and neuropsychological while working with topics such as anger, anxiety/panic, brain healthy practices, bi-polar disorder, cross-cultural recovery, Crisis Counseling, depression, dissociative disorder, disorderd eating and Body Image, emotional and sexual abuse, God-image/Identity in Christ, grief, unresolved pain or loss, and vision drift related to minstry or professional careers. I utilize theology, psychology and spirituality and will often work with a treatment team that includes medical professionals as needed. In the counseling world, what I practice is caleld Christian Psychology. I believe all true healing comes through Christ and will hope to resolve hindrances in your relationship with God and others. AT your discretion we can include direct Biblical applications such as spiritual diciplines or practices. I use tools from several psychological theories: Cognitive/Behavioral, Systemic, and Object Relations theories with techniques from the Accelerated Relational Care Process of Intimacy Therapy; Play, Sand Tray and Art Therapies.

Your Commitment:

My hope is we will work together as long as needed and then you will continue on with your support system. In counseling you have the right to refuse or negotiate modification of any suggestions. Your commitment continues outside of sessions as home-work might facilitate your progress. If you choose to end before we reach your goals please schedule one transition session.

Our Contact:

Our relationship is strictly professionaly therapeutic. If we encounter each other outside of sessions, I will wait for you to being a conversation. Please do not ask me to relate to you in any other way than the professional relationshp. Our contact will be limited to counseling sessions we arrange or you may contact me with questions (512-891-1651), an FEFC Pastor for prayer (512-891-1600), or in the case of an emergency call 911 or the MHMR Help Line (512-472-4357).

Appointement and Fees:

Sessions are held for anywhere from an agreed upon 60 minutes to 4 hours for Mini-Intensives. In the event that you will not be able to keep an appointment, please notify me 24 hours in advance at 512-891-1651. Scheduled apointments that are missed without notification may be charged half of the session fee. Please see the Standards and Policies for additional information. Your payment for these services is expected with each appointment. Session fees begin at $90/session and a sliding scale may be applied when available based on your current available income. If we agree to a fee below $35/session, you will be asked to complete a Service Journal of your community or ministry service to complete payment for each session.

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