Andrea Messineo, LPC, LMFT1720 Sunset Boulevard

Houston, TX 77005Phone: 713-208-9989

e-mail: a.messineo@att.net

Client Information SheetToday's date: _

Your name: Date of birth: Gender: _

Marital status: Number/Ages of children: Social Security #: _

Home street address: Apt.: _

Ci~: _ State: Zip: _

Home/cell phone: e-mail: _

Employer: _

Businessaddress: _

City: _ State: Zip: _

Business phone: e-mail:

Calls or e-mail will be discreet, but please indicate any restrictions: _

If an emergency arises and I cannot reach you directly, or if I need to reach someone close to you, whom should I call?

Name: _ Phone: Relationship:

Address: _ -------------------.---------------

How did you find out about my services? _

May I have your permission to thank this person for the referral? 0 Yes 0 No 0 Not applicable

Have you ever received psychological, psychiatric, or counseling services before?

o No

o Yes (If yes, please indicate:)

When? From whom? For what? With what results?

Have you ever taken medications for psychiatric or emotional problems?

o No

o Yes (If yes, please indicate:)

(Client Information Sheet, p. 2)

Prescription? From whom? For what? With what results?

Abuse history: 0 I was not abused in any way. 0 I was abused. If you were abused, please indicate the kind of

abuse, who abused you, and when ithappened: _

Are you presently suing anyone or thinking of suing anyone? 0 No 0 Yes. if yes, please explain: _

is your reason for coming to see me related to an accident or injury? Q No 0 Yes. If yes, please explain: _

Are you required by a court, the police, or a probation/parole officer to have this appointment? 0 No 0 Yes. If yes,

please explain: _

Is there anything else that is important for me as your therapist to know about, and that you have not written about in

another place on these forms? If yes, please tell me about it here or on another sheet of paper: _

This is a strictly confidential patient medical record Redisc/osure or transfer is expressly ptobibited by law.

Andrea Messineo, LPC, LMFT1720 Sunset Boulevard

Houston, TX 77005Phone: 713-208-9989

e-mail: a.messineo@att.net

Adult Checklist of Concerns

Name: Date: _

Please mark all of the items below that apply, and feel free to add any others at the bottom under "Any other concerns or issues." Youmay add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the "ChildChecklist of Characteristics.")

[) I have no problem or concern bringing me here

[) Abuse-physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals

u Aggression, violence

0 Alcohol use

0 Anger, hostility, arguing, irritability

0 Anxiety, nervousness

[) Attention, concentration, distractibility

0 Career concerns, goals, and choices

0 Childhood issues (your own childhood)

0 Codependence

u Confusion

o Compulsions

0 Custody of children

o Decision making, indecision, mixed feelings, putting off decisions

o Delusions (false ideas)

o Dependence

D Depression, low mood, sadness, crying

[) Divorce, separation

o Drug use-prescription medications, over-the-counter medications, street drugs

o Eating problems-overeating, undereating, appetite, vomiting (see also "Weight and diet issues")

:J Emptiness

:J Failure

o Fatigue, tiredness, low energy

o Fears, phobias

:J Financial or money troubles, debt, impulsive spending, low income

o Friendships

o Gambling (Adult Checklist of Concerns, p. 2)

o Grieving, mourning, deaths, losses, divorce

o Guilt

o Headaches, other kinds of pains

o Health, illness, medical concerns, physical problems

o Housework/chores-quality, schedules, sharing duties

o Inferiority feelings

o Interpersonal conflicts

o Impulsiveness, loss of control, outbursts

o Irresponsibility

o Judgment problems, risk taking

o Legal matters, charges, suits

o Loneliness

o Marital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointments

o Memory problems

o Menstrual problems, PMS, menopause

o Mood swings

o Motivation, laziness

[J Nervousness, tension

o Obsessions, compulsions (thoughts or actions that repeat themselves)

U Oversensitivity to rejection

o Pain, chronic

o Panic or anxiety attacks

o Parenting, child management, single parenthood

o Perfectionism

o Pessimism

o Procrastination, work inhibitions, laziness

o Relationship problems (with friends, with relatives, or at work)

o School problems (see also "Career concerns ...")

o Self-centeredness

o Self-esteem

o Self-neglect, poor self-care

o Sexual issues, dysfunctions, conflicts, desire differences, other (see also "Abuse")

o Shyness, oversensitivity to criticism

o Sleep problems-too much, too little, insomnia, nightmares

o Smoking and tobacco use

o Spiritual, religious, moral, ethical issues

[] Stress, relaxation, stress management, stress disorders, tension

o Suspiciousness, distrust

o Suicidal thoughts

o Temper problems, self-control, low frustration tolerance

o Thought disorganization and confusion

[] Threats, violence

Cl Weight and diet issues

o Withdrawal, isolating

o Work problems, employment, workaholismloverworking, can't keep a job, dissatisfaction, ambition

o O~erconcernsorissues:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~_

(Adult Checklist of Concerns, p. 3)

Please look back over the concerns you have checked off and choose the one that you most want help with. It is:

This is a strictly confidential patient medical record Redisclosure or transfer is expressly prohtbited by law

Andrea Messineo, LPC, LMFT1720 Sunset Boulevard

Houston, TX 77005Phone: 713-208-9989

e-mail: a.messineo@att.net

Consent to Treatment

I do hereby seek and consent to take part in the treatment by the therapist named below. I understand that developing atreatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my bestinterest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by thistherapist.

I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for ispaying for the services I have already received. I understand that I may lose other services or may have to deal withother problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to thecourt.)

I know that I must call to cancel an appointment at least 48 hours (2 days) before the time of the appointment. If I do notcancel and do not show up, I will be charged for that appointment. Payment is due at the time services are rendered,unless other arrangements have been made in advance.

My signature below shows that I understand and agree with all of these statements.

Signature of client (or person acting for client) Date

Printed name Relationship to client (if necessary)

I, the therapist, have discussed the issues above with the client (and/or his or her parent, guardian, or otherrepresentative). My observations of this person's behavior and responses give me no reason to believe that this personis not fully competent to give informed and willing consent.

Signature of therapist Date

This is a strictly confidential patient medical record Redisc/osure or transfer is expressly prohibited by law.

Andrea Messineo, LPC, LMFT1720 Sunset Boulevard

Houston, TX 77005Phone: 713-208-9989

e-mail: a.messineo@att.net

Notice of Privacy Practices (Brief Version)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANDHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

My commitment to your privacy

My practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. I am alsorequired by law to keep your information private. These laws are complicated, but I must give you this important information. This is ashorter version of the attached, full, legally required notice of privacy practices. Please contact me (see the end of this form) about anyquestions or problems.

How I use and disclose your protected health information with your consent

I will use the information I collect about you mainly to provide you with treatment, to arrange payment for my services, and for someother business activities that are called, in the law, health care operations. After you have read this notice I will ask you to sign aconsent form to let me use and share your information in these ways. If you do not consent and sign this form, I cannot treat you. If Iwant to use or send, share, or release your information for other purposes, I will discuss this with you and ask you to sign anauthorization form to allow this.

Disclosing your health information without your consent

There are some times when the laws permit or require me to use or share your information. For example:

1. When there is a serious threat to your or another's health and safety or to the public. I will only share information with persons whoare able to help prevent or reduce the threat.

2. When I am required to do so by lawsuits and other legal or court proceedings.

3. If a law enforcement official requires me to do so.

4. For workers' compensation and similar benefit programs.

There are some other rare situations. They are described in the longer version of my notice of privacy practices.

Your rights regarding your health information

1. You can ask me to communicate with you in a particular way or at a certain place that is more private for you. For example, you canask me to call you at home, and not at work, to schedule or cancel an appointment. I will try my best to do as you ask.

2. You can ask me to limit what I tell people involved in your care or the payment for your care, such as family members and friends.

3. You have the right to look at the health information I have about you, such as your medical and billing records. You can get a copyof these records on request.

4. If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions toyour records to correct the situation. You have to make this request in writing and send it to me. You must also tell me the reasons youwant to make the changes.

5. You have the right to a copy of this notice. If I change this notice, I will post the new version in our waiting area, and you can alwaysget a copy of it from me.

6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me or withthe Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will notchange the health care I provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state,and these may be the same as or different from the rights described above. I will be happy to discuss these situations with you now oras they arise. If you have any questions regarding this notice or my health information privacy policies, please contact me. Theeffective date of this notice is April 1, 2011.

Andrea Messineo, LPC, LMFT1720 Sunset Boulevard

Houston, TX 77005Phone: 713-208-9989

e-mail: a.messineo@att.net

Consent to Use and Disclose Your Health Information

This form is an agreement between you, and me, When I use the words "you" and "your" below, this can mean you, your

child, a relative, or some other person if you have written his or her name here:

When I examine, test, diagnose, treat, or refer you, I will be collecting what the law calls "protected health information"

(PHI) about you. I need to use this information in our office to decide on what treatment is best for you and to provide

treatment to you. I may also share this information with others to arrange payment for your treatment, to help carry out

certain business or government functions, or to help provide other treatment to you. By signing this form, you are also

agreeing to let me use your PHI and to send it to others for the purposes described above. Your signature below

acknowledges that you have read or heard my notice of privacy practices, which explains in more detail what your rights

are and how we can use and share your information.

If you do not sign this form agreeing to our privacy practices, I cannot treat you. In the future, I may change how I use

and share your information, and so I may change my notice of privacy practices. If I do change it, you can get a copy

from me by contacting me at 713-208-9989 or bye-mail ata.messineo@att.net.

If you are concerned about your PHI, you have the right to ask me not to use or share some of it for treatment, payment,

or administrative purposes. You will have to tell me what you want in writing. Although I will try to respect your wishes, I

am not required to accept these limitations. However, if I do agree, I promise to do as you asked. After you have signed

this consent, you have the right to revoke it by writing to me. I will then stop using or sharing your PHI, but I may already

have used or shared some of it, and we cannot change that.

Signature of client or his or her personal representative Date

Printed name of client or personal representative Relationship to the client

Description of personal representative's authority

Signature of authorized representative of this office or practice

DateofNPP: _ o Copy given to the client/parent/personal representative