KEVIN DOYLE, LPC, LSATPCLIENT INFORMATION SHEET

(please print)

Client Name: ____________________________________________

Address: ____________________________________________

____________________________________________

Phone: ___ __(_____)_______________________________(mark which numberyou prefer us to use) ___ __(_____)_______________________________

E-Mail (optional): ____________________________________________

Date of Birth: ___/___/___ Permission to text: Y N E-Mail: Y N

Employer/School: ____________________________________________

Referred by (phone): ___________________________(____)___________

Parent/Guardian: ____________________________________________(if applicable, minor client)

Appointment Reminder: Yes No (circle one) Method: Text Email Phone (circle one)

Describe reason for seekinghelp, in your own words: ______________________________________________

______________________________________________

______________________________________________

How did you hear aboutmy practice? _____________________________________________

______________________________________________

OFFICE USE ONLYReleases to speak with: 1.____________________ 2. ___________________

3. ____________________ 4. ___________________

Kevin Doyle, Ed.D., LPC, LSATPwww.drkevindoyle.com

A Limited Liability Company(434) 974-0997

kevin@drkevindoyle.com

INFORMED CONSENT

The purpose of this document is to introduce myself to you as a prospective client, to describe the counseling process, to involve you in structuring your counseling experience, and to cover some of the logistical arrangements regarding counseling.

Your Counselor: I hold an Ed.D. in Counselor Education from the University of Virginia, and an Ed.S. in Counseling Psychology from James Madison University. I am licensed as a Professional Counselor (License No. 071001316) and as a Substance Abuse Treatment Practitioner (License No. 0718000144) in Virginia. Please feel free to call me by my first name, if you are comfortable with that. I have worked in inpatient, outpatient, and residential substance abuse treatment settings for over 25 years. My clinical work has focused largely on substance abuse treatment and recovery, including work with adolescents, families, athletes, and people with co-occurring substance use and mental health disorders. My theoretical orientation for counseling and supervision is an integration of cognitive-behavioral, reality therapy, and person-centered approaches. As your counselor, I will attempt to use my skills and training to help you with identified issues, facilitate your personal growth, and be of assistance to you in whatever way that we identify together that might be helpful and appropriate. Counseling may or may not be of assistance to you as a client and should be undertaken with that knowledge. If you believe your sessions are not helpful, please inform me so that we may discuss that. If you believe I have behaved unprofessionally, I also ask that you discuss that with me, but you may also report such to the Virginia Board of Counseling, through which I am licensed to practice via its web site: www.dhp.virginia.gov/counseling. Logistics: All sessions are by appointment and will be held on a scheduled basis. Individual sessions will generally last for 30, 45, or 60 minutes, and groups for 75 minutes, at my office at 404 8th St., N.E., Charlottesville, VA. Please arrive promptly as sessions will begin on time. Parking is free and available in the lot adjacent to the building, as well as on the street. In the event that you are unable to attend a session please contact me ahead of time. You may leave a message on my confidential voice mail or send an e-mail message (kevin@drkevindoyle.com) if you are unable to reach me personally. Should you need to contact me between sessions, you may reach me at either of the numbers above or via e-mail. Please note that email is not always a secure mode of communication, so you may wish to limit what you include in email messages. I will not transmit protected health information (PHI) by email, but it can be helpful for appointment setting and confirmations. Social media (Facebook, Twitter, etc.) are not appropriate means for communication between us, so please do not utilize those for communication with me.

Emergency: My practice is a sole, part-time practice, and I am not equipped to handle emergencies. If you have a personal, medical, or mental health emergency you are advised to seek help at the nearest hospital emergency room or by calling 9-1-1. By signing this, you agree to inform me if you are having any thoughts of harming yourself, and/or to seek immediate emergency assistance if that occurs.

Financial Obligation: I accept cash, checks, and major credit cards, and payment is to be made at the beginning of each session. See the accompanying rate sheet for current rates, which are subject to change. The hourly fee also applies to report preparation and court testimony (including travel time). There is a $30 charge for a returned check regardless of reason, and the full session rate is charged for missed appointments when notice is not given one business day in advance (24 hours). Clients are also responsible for all collection costs, should an account be referred to a collection agency.

Confidentiality: I will maintain, respect, and protect your privacy and confidentiality as set forth by relevant laws, regulations and codes of ethical and professional conduct. I will not reveal anything about your identity or your counseling without your permission except when I am compelled to do so to protect your safety or that of another person(s), in cases of mandated reporting of child/elder abuse, by subpoena or court order, or for other limited reasons specified by law. If I would happen to see you around town or in any social setting, I will not acknowledge knowing you unless you initiate such recognition or acknowledgement. Finally, I serve as the designated Privacy Officer for the practice. If you would like me to be able to speak to another person or entity on your behalf, please inform me and I will provide you with a consent form to complete and sign. I ask that you do not disclose to anyone the identities of any other clients whom you might see here, whether in a group counseling setting or in passing. Please know that I do not control the release of any information you may choose to share with other group members.

Statement of Agreement: I have read and understand the information in this document, have had the opportunity to ask questions, and agree to comply with it.

_______________________ ______ ______________________ ______Client Signature Date Parent/Guardian Signature Date

(if applicable)

_______________________ ______Witness Date

Rev. 5/15

Kevin Doyle, Ed.D., LPC, LSATPA Limited Liability Company

www.drkevindoyle.comkevin@drkevindoyle.com

(434) 974-0997

RATE SHEET

Individual Session (extended, 60 minutes): $ 160

Individual Session (standard, 45-50 minutes): $ 140

Individual Session (brief, 30 minutes): $ 80

Group Session $ 50

Evaluation (90 minutes, fee includes write-up): $ 200

Urinalysis/Drug Screening: $ 40

Provider Note: I do not participate with any health insurance plans at present, but will be happy to provide you with paperwork to assist in your submission to your health insurance provider for reimbursement. I accept cash, checks, and major credit cards.

Statement of Agreement: I have read and understand the information in this document and agree to comply with it. I assume responsibility for all fees, including collection fees should account become overdue. I understand that payments are due at the time of the session and that cancellations with less than 24 hours notice will be billed at the full session rate.

_________________________ ______ ________________ ______Financially Responsible Party Date Print Name DateSignature

_________________________ _________________ ______Client Name (if different) Witness Date

Rev. 1/16

Kevin Doyle, Ed.D., LPC, LSATP, LLC www.drkevindoyle.com

kevin@drkevindoyle.com

ELECTRONIC COMMUNICATION STATEMENTAlthough the Health Insurance Portability and Accountability Act (HIPAA) likely does not apply to my practice as I do not engage in electronic transmission of records or protected health information (PHI), I do strive to maintain the highest level of security and confidentiality to protect client privacy.One provision of the HIPAA 2013 Omnibus Rule affirms client autonomy and allows clients to receive unencrypted email communication if they “opt in” to this means of communication. Clients do need to understand that not all email communication can be guaranteed to be 100% secure and that there is the possibility that email could be read by a third party. I have found email to be a good way to communicate with clients while not revealing any clinical details or protected health information, such as for scheduling appointments. If you are comfortable with this and agree to it, please “opt in” below. Likewise, please opt in or opt out for text messaging, which will be used only in the same manner. As always, in case of emergency, please call me (434-974-0997), call 911, or go to your nearest hospital emergency room.Please let me know if you have any questions or concerns.

___ Yes, I opt in to receiving electronic mail (note my email address: kevin@drkevindoyle.com)

___ No, I opt out and do not give permission for email communication.

____ Yes, I opt in to receiving text messages.

____ No, I opt out and do not give permission for communication via text messaging.

Signature: ______________________ Printed Name: ____________________ Date:_________