Welcome to the Touch of Healing Counseling Center! We provide services by licensed therapist
and counselors. In cooperation with the ministries of First Assembly of God in Griffin and Dr.
Randy Valimont, Senior Pastor has initiated this counseling ministry to provide to all parties who
seek professional assistance for individual, marriage, or family issues, regardless of their race,
color, or religious affiliation. It is the goal of this counseling ministry to assist those struggling
with the cares of this life to find wholeness, which can only be found in Christ Jesus, our Lord
and Savior.
Christian Counseling is a joint venture of the counselor and the client, whereby healing and
restoration are sought through mutual insight exchange, behavioral change, and spiritual
renewal. As such, your therapist greatly depends upon you to adhere strictly to the following
criterion in order that your investment reaps optimal results.
Our Therapists
Sandra Rawlings, MS, LPC, Director
Terry Borsare, MA, LPC
Karyn Kochan, MS, LPC, CLC
Amanda Scott, MA, LMFT
Rita Gramme, MA
Cathy Kleinschmit, MA, APC
Cynthia Midgett, MA
Tonya Shirey, MS
APPOINTMENTS:
Please contact the counseling office to schedule a counseling session. Unless prior
arrangements have been made all co-pays and fees are due at time of service. If it
becomes necessary to cancel, please notify the office 24 hours prior to your scheduled
appointment session. Should failure to attend by no/little advance notice become an
issue, you will be subject to a fee of $25.00. In the event of your 2nd no show, you
must pay those fees prior to your next scheduled session.
Date: _____________________________
Have you ever been seen in our office before? _______
PATIENT INFORMATION
Patient Name: __________________________________________________________________________
Patient date of birth: __________________
Patient gender: M______ F_______
Legal Guardian name _____________________________________________ Relationship_____________
Patient Address: __________________________ City ____________ State _____ Zip __________
Email: ____________________________________________________________________
Phone: ________________________________________ (home)
Phone: ______________________________________ (cell) ______________________________ (work)
Emergency contact: ___________________________________________ Phone____________________
How did you hear about us? _________________________________________________________
Does your insurance require an authorization for services? __________
INSURANCE POLICY HOLDER
Policy holder name: __________________________________________ Date of birth:_______________
Patient relationship to policy holder (self / child / spouse): __________________________
Name of insurance company: ________________________________ Member ID #: _________________
Group/policy number: ________________________________
Policy holder employer name: _______________________________________
ALL SESSIONS ARE 45 MINUTES LONG. LATE ARRIVALS WILL SHORTEN YOUR SESSION DUE TO OUR
SCHEDULE.
Patient Personal Information
Name: ________________________________________
Marital status: _______________________
Religious Affiliation: _______________________________ Church: _________________________
Employed: Yes _____ No _____ Name of Employer: _________________________________________
Type of work: ___________________________________________________
Family Members
Relationship
Name
Age
Last Grade
Completed
Occupation
Spouse
Father
Mother
Brother (s)
Sister (s)
Children
Describe any physical problems you have that require medication or physical care:
_________
Are you currently receiving medical treatment or taking prescription medications?  yes  no
If yes, please list:
_________
Have you had previous counseling?  yes  no If yes, when?
________
Where and with whom?
Name
Address
In your own words, briefly describe the main problem which prompted you to seek counseling at this
time:
Have there been times when the problem got better or disappeared?  yes  no
What do you think helped?
Were there times when the problem was especially bad?  yes  no
What made it so bad?
Are there other people who play a major role in causing your problem or are helping you to cope with
your problem?  yes  no
Explain briefly:
_______
Problem Area
In the following list, place a check mark next to each item which identifies an area of concern to you.
Place two check by those items which are most important. (You may add comments after areas checked.)
Anger
Religious/Spiritual Concerns
Depression
Sexual Concerns
Education
Thoughts of suicide
Eating difficulties
Trouble making decisions
Fearfulness
Unhappy most of the time
Financial problems
Use of alcohol
Marital problems
Physical problems
Problems with social relationships
______Use of alcohol by family member
Use of drugs
_____Use of drugs by a family member
Problems with children
Work
Problems with parents
Worry
REGARDING TESTIFYING IN COURT:
1.
2.
3.
4.
Only Current Licensed or Ph.D level therapist are to testify.
To testify, the therapist must receive a subpoena.
Signed authorization is a must if testifying for someone as a spouse or child.
Client’s rights are waived by testifying in court, in that they are giving permission to reveal
confidential information.
During the course of the counseling session it may be necessary to request documentation
information from your therapist for Attorneys, Human Resources Managers, Correction Officers,
Courts, etc. Our practice guidelines are to provide a notarized affidavit for a cost of $75.00 to the
client. Affidavits are legal documents used in court. In the event the therapist is subpoenaed to
court, the client agrees to pay $125.00 per hour for each hour the therapist is out of the office,
with a minimum of two hours to be paid prior to Court. Payment is the responsibility of the
client, as insurance companies do not cover court costs or loss of income for the therapist. The
balance is due within 7 days after the hearing. Fees will be charged to your credit card on file
unless other arrangements have been made.
ALL CLIENTS:
Payment from cash clients is due at the time of service. We accept cash, check, Visa, Master Card,
Discover and/or Debit Card. A $30.00 fee is charged for all checks returned from the bank for any
reason. A billing statement or receipt is generated only upon request. In order to maintain standing
appointments, your account must be kept current.
Clients who are Minors:
The adult accompanying a minor of the parent/guardian (s) is responsible for full payment.
Minors unaccompanied by an adult will be denied services (except in an emergency) unless payment has
been prearranged.
In addition to the above, I hereby waive the statute of limitations on collection and/or recovery in the
state of Georgia.
EMERGENCY PROCEDURES:
All phone contact should be directed primarily to (678) 688- 3133. In cases of crisis where the therapist
has not made other arrangements, notify 911 or the local emergency room.
I have read the above statements and acknowledge by my signature below that I fully
understand them and have no further questions.
Signature_____________________________Date___________________________
Witness______________________________Date___________________________
STATEMENT OF CLIENT RIGHTS
1.
You have the right to be treated in a consistently competent, ethical, and respectful manner.
2.
You have the right to stop receiving therapy without any obligation other than to pay for the
services you have already received.
3.
You have the right to ask questions about the approach and methods utilized, and to decline the
use of certain therapeutic techniques.
4.
You have the right to review your individual clinical records at any time.
5.
You have the right of confidentiality. This means that, within the limits described below, we will
not release identifying information about you to any person or agency without your permission.
6.
In certain situations, we are required by law to reveal information about you to other persons or
agencies WITHOUT YOUR PERMISSION.
a.
If you threaten grave bodily harm or death to another person, we are required to inform
the intended victim and/or appropriate law enforcement agencies.
b.
We are required to release to a court of law any information specifically described by a
court order.
c.
We are required to report to the Department of Family and Children’s Services any
reasonable suspicion we have that a minor is being abused or neglected by you.
d.
If a court of law has ordered you to have treatment or testing, the results of that
treatment or testing must be revealed to the court requesting the information.
I have read the above statements and acknowledge by my signature below that I fully understand them
and have no further questions.
___________________________________________
Signature of Client or Guardian
_____________________
Date
____________________________________________
Witness
_____________________
Date
Notice and Agreement of Legal Issues, c/o Fresh Touch of Healing, LLC
Legal issues in the clinical relationship can include, but are not limited to, the
following: Court room procedures, depositions, testimonies, clinical summaries, and
court appearances
Disclaimer: Fresh Touch of Healing, LLC, hereinafter referred to as FTOH, understands that there
are certain situations that require clients to become involved in legal proceedings. Such legal
proceedings can include, but are not limited to: criminal hearings/trials, drug court, mental
health court, custody issues, divorce, visitation rights, and DFCS referrals. FTOH is willing to
cooperate with the client and other parties upon the following stipulations:
1. ______ FTOH is willing to provide a comprehensive, clinical summary detailing assessments,
diagnoses, session notes, treatment plans, and clinical progress. An adequate and reliable
summary requires a minimum of six (6) sessions, at standard industry duration and at standard
rate, in order to complete a comprehensive, clinical summary. The fee for the clinical summary,
which does not include the fee for the minimum six (6) sessions, is one hundred fifty and 00/100
($150.00) dollars per clinical summary.
2. ______ FTOH is willing to appear in court as a witness on behalf of the client upon the
following stipulations:

FTOH is requested to appear in court without being subpoenaed.

Receiving a subpoena to appear in court will be understood as a change of relationship
between the client and the counselor. The relationship will change from a clinical
relationship to a legal relationship. This change may result in termination of the client
from the practice of FTOH due to the broken clinical relationship.
3. ______ If FTOH agrees to testify as a witness, expert or otherwise, on the client’s behalf,
FTOH would request to be allowed to stay on site at the practice and be given a one-hour notice
(or other reasonable time necessary to appear depending on location of the courthouse) prior
to being called as a witness in court or any other legal proceedings. The client understands that
there is a fee of one hundred fifty and 00/100 ($150.00) dollars charged, per hour, in order to
reimburse FTOH for loss of clinical time during court or any other legal proceedings. This fee is
not reimbursable by insurance and will be paid by the client prior to appearing in court or any
other involvement of legal proceedings.
FINANCIAL POLICY
Promise to Pay Account
For services rendered, I promise to pay Touch of Healing Counseling Center all charges for services. I
hereby authorize insurance payments to be sent to Touch of Healing Counseling Center for services
rendered. I am aware that I am financially responsible to Touch of Healing Counseling Center for all
charges regardless of insurance payment outcomes.
I acknowledge that I have received a copy of Touch of Healing Notice of Privacy Practice for Protected
Health Information. I understand that Touch of Healing has the right to change its notice of Privacy
Practice for Protected Health Information.
Payments for all services will be due at the time services are rendered. In order to better serve you, we
accept cash, check, Visa, and MasterCard. As a courtesy to you, we will verify your coverage and bill your
insurance carrier on your behalf; however, you are ultimately responsible for the entire bill.
As the responsible party, please understand:
(PLEASE INITIAL THE FOLLOWING)
_________ Your insurance policy is a contract between you, your employer (if applicable), and
your insurance provider. We will not become involved in disputes between you and your insurer
regarding deductibles, co-payments, covered charges, secondary insurance and “usual” and
“customary” charges. As your medical provider, we will only supply factual information to
facilitate claims processing.
_________ I understand that I may have an insurance plan that restricts my therapy, either by
units or by payable dollar amount, and that it is my financial responsibility for the differences
between services covered by my policy and the actual services provided.
_________ I understand that FTOH does not participate with or file claims to Medicare.
_________ Returned checks and unpaid balances may be subject to collection placement and
collection fees. I will be responsible for all costs of collecting monies owed including processing
fees.
We understand financial problems may affect timely payment. We encourage you to
communicate any such problems so that we may assist you in keeping your account in good
standing.
Name____________________________________Date______________________
Witness__________________________________Date______________________
HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY
BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE
REVIEW CAREFULLY.
Summary:
By law, we are required to provide you with our Notice of Privacy Practices (NPP). This notice
describes how medical information may be used and disclosed by us. It also tells you how you
can obtain access to this information. As a client, you have the following rights:
1. The right to inspect and copy your information.
2. The right to request corrections to your information.
3. The right to request that your information be restricted.
4. The right to request confidential communication.
5. The right to a report of disclosures of your information.
6. The right to a paper copy of this Notice.
7. The right to file a complaint if you feel your privacy has been violated.
We want to assure you that your medical/protected health information is secure with us. This
notice contains information about how we will insure that your information remains private.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have received a copy of Fresh Touch of Healing Counseling Center, LLC
NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy
rights, that I may contact the person named as the Privacy Officer. I further understand Fresh Touch of
Healing Counseling Center, LLC will offer updates to me regarding this NOTICE OF PRIVACY PRACTICES,
should it be amended, modified, or changed in anyway.
Client Name/Person Authorized To Sign___________________________Date_____________
Witness____________________________________Date___________________
Client unable to sign because__________________________________
Client refused to sign_______________________________________
CONFIDENTIALITY:
I understand that information obtained during the course of treatment will not be released without
consent, except in the case of emergency or as required by law. I understand that confidentiality is waived
in the following circumstances: (1) If a client becomes a danger to self or others, (2) if session records are
subpoenaed by court of law, (3) in case of physical or sexual abuse of minors, the elderly, disabled, or
incompetent others. I also authorize Fresh Touch of Healing to release any and all information regarding
diagnosis, treatment, and prognosis with respect to any mental condition and / or treatment to my
insurance company (s) or its legal representative as indicated. Any such disclosure shall be limited to
information that is reasonably necessary for the discharge of legal and contractual obligation of the
insurance company (s). I understand the information obtained by use of this authorization will be used by
the insurance company (s) to determine eligibility benefits under existing policy. In the event that Fresh
Touch of Healing experiences a breach in security, we will contact clients and law enforcement.
AUTHORIZED PATIENT NOTIFICATION LIST
(Required of HIPAA) Health Insurance Portability and Accountability Act
I authorize all Fresh Touch of Healing Counseling Center, LLC employees and / or whomsoever
he/she may designate as his/her professional representative/assistant to discuss any aspect of
my care.
I am giving the following designated people permission to inquire about my care:
_______________________________
__________________________________
_______________________________
__________________________________
This document will be a part of your permanent record. In the event that any of the selected
representatives that you have designated change, it will be necessary to update our records
with written notification. You will need to state who you would like to have removed and/or
added to the Authorized Notification List.
________________________________________________________
Client/Other Person Authorized To Sign:
_______________
Date:
________________________________________________________
Witness
________________
Date:
I hereby consent for Fresh Touch of Healing Counseling Center to treat the undersigned
person. I authorize Sandra B. Rawlings, MS, LPC and/or her designated staff to render to
the patient customary care, tests, and procedures ordered by Sandra B. Rawlings, MS,
LPC. No identifying information will be released without written consent, except in the
case of emergency or as required by law. Information regarding my involvement in
outpatient counseling will be kept confidential by Fresh Touch of Healing Counseling
Center. For clients age 17 or under, the signature of his/her legal guardian or custodial
parent is required.
Signature
Date
Parent or Guardian
Date
Witness
Date
RELEASE OF INFORMATION AUTHORIZATION
I hereby request and authorize:
Fresh Touch of Healing, LLC (Sandra Rawlings MS., LPC)
(Name of Persons or Agency Requesting / Receiving Information)
2000 West McIntosh Road, Griffin, Georgia 30223
(Address)
And
_____________________________________________
(Name of Persons or Agency Sending / Receiving Information)
_____________________________________________
(Address)
To obtain from each other the following type (s) of information from my records (and any
specific portion thereof): ______________________________________________________________________________
__________________________________________________________________________________________________________
For the purpose of: ____________________________________________________________________________________
___________________________________________________________________________________________________________
_______ This authorization shall remain in effect for one year from the date of the signature below.
_______ The consent can be withdrawn upon notification.
________________________________________________________
Client Signature:
____________
Date:
________________________________________________________
Signature of Parent or Authorized Representative:
________________________________________________________
Signature of Witness/Title:
____________
Date:
The following form, which will become a part of your confidential record, will enable us to gain a
quicker understanding of you. Please answer each question as completely and carefully as you
can. You may use the back of any page for additional information.
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize and request the disclosure of protected information from:
_________ _____________________________
Name of Healthcare Facility to release medical information:
Coker Pediatrics
14557 U.S. Highway 19, Suite A
Griffin, GA 30224-9582
To release health information about the following patient:
Client Name___________________________________Date of Birth__________________
Client Address______________________________________________Ph number: _________
I expressly request that the information in the designated record set be disclosed for date(s)
of service: _____________________________________________ to include the following:
____History & Physical
____Discharge Summary
____Consultations
____ Operative Reports
____Progress Notes
____Outpatient Rehab
Records
____Lab Reports
____Radiology Reports
____EKG
____Emergency Center
____Pathology Reports
____Health Center/Clinic
____Physician’s Orders
____Cardiovascular
____Diagnostic Reports
____Urgent Care Records
____Hospice Records
____Other (specify) _____
This protected health information is disclosed for the following purpose(s):
____Insurance
____Continued Treatment
____Client’s / Client’s Representative’s Request
____Legal
____ Other (specify) _______
You are authorized to release the above records to the following:
Name of Client/Person authorized to sign:
_____________________________________________Date_________________
Witness______________________________Date__________________________