Forms

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=210 BGCOLOR="#99CC99" TEXT="#080000" bgproperties="fixed" background="1552c963.jpg"> <div> <A HREF="mailto:wmeades@gmail.com" TARGET="_top" TITLE="mailto:wmeades@gmail.com"><U><IMG SRC="6799c150.png" border=0 width="156" height="21" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <bR> <div> <A HREF="http://practicalspirituality.wordpress.com/" TARGET="_top" TITLE="http://practicalspirituality.wordpress.c"><U>Practical Spirituality Blog</U></A></div> <bR> <div> <A HREF="counseling.htm" TARGET="_top" TITLE="Pastoral Counseling"><U>Making an Appointment</U></A></div> <bR> <div> <A HREF="printableform.htm" TARGET="_top" TITLE="Forms"><U>Information Form</U></A> </div> <bR> <div> <A HREF="map.htm" TARGET="_top" TITLE="Directions to Office"><U>Map to My Office</U></A></div> <bR> <div> <A HREF="speaking.htm" TARGET="_top" TITLE="Speaking and Teaching"><U>Speaking and Teaching</U></A></div> <bR> <div> <A HREF="enneagram.htm" TARGET="_top" TITLE="The Enneagram"><U>The Enneagram</U></A> <A HREF="enneagram.htm" TARGET="_top" TITLE="The Enneagram"><U> </U></A></div> <bR> <div> <A HREF="http://www.wfmhc.org/" TARGET="_top" TITLE="http://www.wfmhc.org/"><U>Waco Foundation for Mental Health Care</U></A></div> <div> <B>____________________</B></div> <div> <A HREF="index.htm" TARGET="_top" TITLE="Practical Spirituality"><U>Home</U></A></div> <div> <A HREF="aboutme.htm" TARGET="_top" TITLE="About Me and My Work"><U>About Me and My Work</U></A></div> <div> <A HREF="personalspiritualdevelopment.htm" TARGET="_top" TITLE="Personal and Spiritual Development"><U>Personal and Spiritual Development</U></A></div> <div> <A HREF="helpfularticles.htm" TARGET="_top" TITLE="Helpful Articles"><U>Helpful Articles</U></A></div> <div> <A HREF="booksummaries.htm" TARGET="_top" TITLE="Book Summaries"><U>Book Summaries</U></A></div> <div> <A HREF="counseling.htm" TARGET="_top" TITLE="Pastoral Counseling"><U>Pastoral Counseling</U></A></div> <div> <A HREF="premarriage.htm" TARGET="_top" TITLE="Premarriage Counseling"><U>Premarriage Counseling</U></A></div> <div> <A HREF="id332.htm" TARGET="_top" TITLE="Practical Spirituality Newsletter"><U>Practical Spirituality Newsletter</U></A></div> <div> <A HREF="clericus.htm" TARGET="_top" TITLE="Clericus"><U>Clericus</U></A></div> <div> <A HREF="id523.htm" TARGET="_top" TITLE="DS Parenting Class"><U>DS Parenting Class</U></A></div> <div> <A HREF="http://centexintergroup.org/schedule/schedule_local.htm" TARGET="_top" TITLE="http://centexintergroup.org/schedule/sch"><U>Alcoholics Anonymous Meetings Schedule</U></A></div> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> Before we meet I need to get some info from you and I need for you to look over my policies.  Also, this page concludes with a "Commitment to Treatment" statement that I'd like for you to consider carefully.  You can get this information to me via email, or by printing it out.</div> <bR> <div> <B>To email:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hit CTRL-A, which will highlight everthing on this page.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hit CTRL-C, which will copy this page to your computer's clipboard.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Click  <A HREF="mailto:wmeades@gmail.com" TARGET="_top" TITLE="mailto:wmeades@gmail.com"><U><IMG SRC="6799c150.png" border=0 width="156" height="21" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A> , which will open an email to me.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Click in the body of the email and then click CTRL-V, which will copy this page into the email.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">You can now fill out the form and forward it to me.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Keep in mind that this is NOT a confidential way to send me information.</div> <bR> <div> <B>To print out:</B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hit CTRL-A, which will highlight everthing on this page.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hit CTRL-C, which will copy this page to your computer's clipboard.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Open your word processing program (MS Word, MS Works, WordPerfect, etc).</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Click in the body of a new document and then click CTRL-V, which will copy this page into the page.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">You can now fill out the form and print it.</div> <bR> <bR> <div> <B>I CANNOT GAURANTEE EMAIL CONFIDENTIALITY:</B> A simple & free encryption program can be downloaded at <FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.pc-encrypt.com/_site/alock/index.mhtml" TARGET="_top" TITLE="http://www.pc-encrypt.com/_site/alock/in"><U><U>http://www.pc-encrypt.com/_site/alock/index.mhtml</U></U></A></FONT>.  If you want to use this program, then install it on your computer and then call me to leave your passcode with me.</div> <bR> <div> <B>Directions to my office:</B> <FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.wmeades.com/map.htm" TARGET="_top" TITLE="http://www.wmeades.com/map.htm"><U><U>http://www.wmeades.com/map.htm</U></U></A></FONT></div> <bR> <div> <B>Enneagram Personality Inventory.</B>   Please take the free Enneagram Personality Inventory by <A HREF="http://similarminds.com/advtest.html" TARGET="_top" TITLE="http://similarminds.com/advtest.html"><U>clicking here</U></A> and email me the results.  For more info on the Enneagram, <A HREF="enneagram.htm" TARGET="_top" TITLE="The Enneagram"><U>click here.</U></A></div> <bR> <div> <B>the Practical Sprituality Blog:</B>  If you would like to subscribe to my blog, where I write on various subjects related to personal growth, spiritual maturity, and relationships, then please go to the <A HREF="http://practicalspirituality.wordpress.com/" TARGET="_top" TITLE="http://practicalspirituality.wordpress.c"><U>Practical Spirituality Blog</U></A>.  (At the top right you will see an option to subscribe via email.  Subscribing will get you an email notification whenever I post something new.</div> <bR> <div> <A HREF="authself.htm" TARGET="_top" TITLE="The Authentic Self by Burt Burleson"><U><B>"The Authentic Self"</B></U></A><B> </B>is a series of 4 lessons by Burt Burleson, the chaplain at Baylor University.  In these brief lessons Burt describes the concepts of "small self" and "Authentic Self," which have a long history in the area of spirituality.  I have found these concepts to be very helpful to my clients was we discuss the various challenges they bring to me.  This is recommended reading for all my clients.</div> <bR> <div> <B>GENERAL INFO</B></div> <bR> <div> Name (last, first, middle): </div> <div> Street:</div> <div> City/State/Zip:</div> <div> Social Security:</div> <div> Birth Date:</div> <div> Age:</div> <div> Sex:</div> <div> Marital Status:</div> <div> Employer:</div> <div> Email:</div> <div> Home Phone:</div> <div> Work Phone:</div> <div> Cell Phone:</div> <div> Where may I leave messages?: </div> <bR> <div> <B>Who will be responsible for paying your account? (if different from above):</B>   </div> <div> Name:</div> <div> Street: </div> <div> City/State/Zip:</div> <div> Home Phone:</div> <div> Work Phone:</div> <div> Cell Phone:</div> <div> Email:</div> <bR> <div> Emergency Contact (Name, address, phone):</div> <bR> <div> <B>Present Medications (please include dose and frequency):</B></div> <bR> <bR> <bR> <div> <B>INSURANCE INFORMATION</B></div> <bR> <div> <FONT SIZE="2" COLOR="#000000" FACE="Arial" ><B>Those with Blue Cross Blue Shield Health Insurance please </B></FONT><A HREF="id477.htm" TARGET="_top" TITLE="Blue Cross Blue Shield Clients"><U><B>click here</B></U></A></div> <bR> <div> <TABLE BORDER="2" CELLPADDING="10" CELLSPACING="1" WIDTH="791" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#DDDDDD HEIGHT= 352 WIDTH="763"><div> NOTE: </div> <div> It is very important that you contact your insurance company before the first appointment in order to clarify your coverage for mental health care (the single most time consuming administrative issue I deal with is working out problems with insurance coverage).  The best way to get this information is by calling the number on your insurance card.  You may notice that there is a different number for mental health related questions.</div> <bR> <div> If you are able to get all the following information clarified, then I'll be glad for you to pay only your portion of the fee.  However, if you prefer for me to get this information on your behalf, then I'll ask you to pay my standard fee ($115) until I have time to get this info.  Info I'll need:</div> <bR> <div> Am I "in-network" or "out-of-network" on your policy?:</div> <div> How much is your deductible?:</div> <div> How much of your deductible remains to be covered?:</div> <div> What is your co-pay for seeing me?:</div> <div> Is precertification required?:</div> <div>        If so, ask the agent to go ahead and set up the precertification.</div> <div>        Precertification info can be faxed to me at (254) 230-4401.</div> <bR> <div> If it turns out that you still need to meet a deductible, and paying the full fee until the deductible is met creates a hardship for you, then I'll work out a plan with you for you to pay off a portion of the deductible with each session.</div> </tD> </tR> </TABLE></div> <bR> <div> Insurance Company Name:     </div> <div> Insurance Company Phone Number:   </div> <bR> <div> In order to file on your insurance, I'll need a copy of your card, along with general information requested above.  If you are not the primary policy holder, then I'll need the following info on the primary policy holder:</div> <bR> <div> Insured's Name (Last, First, M.I.): </div> <div> Insured's Street Address: </div> <div> Insured's City/State/Zip:   </div> <div> Insured's Phone # (Include AC): </div> <div> Insured's Date of Birth: </div> <div> Insured's Sex: </div> <bR> <div> <B>REQUEST FOR FEE SUBSIDY</B></div> <bR> <div> The  <A HREF="wf.htm" TARGET="_top" TITLE="Waco Partnership for Psychological and S"><U>Waco Partnership for Psychological and Spiritual Care (WPPSC)</U></A> exists to help people afford the cost of counseling.  My standard fee is $115 per session.  The Foundation makes it possible for me to discount my fee.  Because the Foundation's resources are limited, and because the board believes it is important for persons to take as much responsibility as possible for the cost, you are asked you to provide the following information so a fee can be calculated: </div> <bR> <div> 1.  What is your approximate monthly "take home" income?</div> <bR> <div> 2.  How many children do you have living in your home or support in college?</div> <bR> <div> 3.  What other sources of income can help with your counseling fees (for example, are other family members willing to help with the cost of counseling?; does your religious congregation provide some support for counseling?)</div> <bR> <div> 4.  What particular financial stresses are you up against that are beyond your control (for example, medical bills due to illness,  financial problems due to divorce, etc.)</div> <bR> <div> 5.  How much do you believe you can afford to spend each month on counseling services?</div> <bR> <bR> <div> <B>Focus Form</B></div> <bR> <div> To what degree do the following statements apply to you?  Respond using the following scale:</div> <div> <B>1</B> = not at all true    <B> 2</B> = perhaps a little true    <B>3</B> = fairly true   <B>4</B> = very true</div> <div> <I>(Please place your response in front of the statement)</I></div> <bR> <div>       I need to deal with a particular situation I can describe clearly.</div> <div>       I am seeking to understand myself better.</div> <div>       I need help getting through a difficult experience.</div> <div>       I usually handle everything fine, but there's just too much happening now.</div> <div>       I need to talk about things that happened to me in my growing up years.</div> <div>       I need some ideas about how to handle a particular circumstance.</div> <div>       I would like to discuss my spiritual concerns.</div> <div>       I would like counseling for someone close to me.</div> <div>       I can name exactly what I need to work on.</div> <div>       I am concerned about the amount of alcohol I am drinking.</div> <div>       I am having suicidal thoughts.</div> <div>       I do not need counseling; I am here because someone insisted I come.</div> <div>       I find reading books to be helpful in dealing with problems.</div> <div>       I seem to keep making the same mistakes over, even though I try not to.</div> <div>       I am wondering if I need medications to help with the way I feel.</div> <div>       I sense that God is part of what I am going through.</div> <div>       It is extremely important that I come for counseling.</div> <div>       I am here out of concern for some religious issue(s).</div> <div>       I need to discuss my problem with alcohol, drugs or other painful behavior.</div> <bR> <div>       How many sessions of counseling do you imagine you'll need or want?</div> <bR> <div> <B>POLICIES</B><FONT SIZE="2" COLOR="#000000" FACE="Arial" ><B> </B></FONT></div> <bR> <div> <I><B>A Summary of My Policies </B></I><I>(You will be asked to sign a form indicating you have read and understood the detailed policies: </I><A HREF="id458.htm" TARGET="_top" TITLE="Policy Details"><U><I>Policy Details</I></U></A><I> )</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The fee is due at the end of the session unless other arrangements have been agreed up.  The standard fee is $115/hour.  Insurance may cover a portion of this fee.  You may qualify for a fee subsidy through the Waco Foundation for Mental Health Care</div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">You are responsible for clarifying the insurance benefits with your company. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Appointments last 45-55 minutes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">24 hours notice is required to cancel or change an appointment without being charged for that appointment. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Confidentiality is strictly kept.  The only exception is when I believe your safety or the safety of others is at risk. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700dc00000000.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Email is not a confidential form of communication.   If you wish to guarantee that our emails be confidential, then you must initiate the use of the free email encryption program that I use.</div> <bR> <bR> <div> <B>Info for which I need a real live signature </B><FONT SIZE="2" COLOR="#000000" FACE="Arial" >(I'll need a hard copy of this info.  I have a single page form at my office you can use, or you can cut and paste this section into you word processor, print, and sign.)</FONT></div> <bR> <div> Name________________________________________________ Date of Birth____________________ </div> <bR> <div> Referral_____________________________________ Relationship to Referral_____________________</div> <div> May Dr. Eades notify the referral that you've come for an appointment?    ___Yes    ___No If yes, please initial _______ </div> <bR> <div> Pastor/Congregation___________________________________________________________________ </div> <div> May Dr. Eades notify the pastor that you've come for an appointment?     ___Yes    ___No If yes, please initial _______</div> <bR> <div> Consultation : You have my permission to consult with the following persons who may be of help:</div> <div> Name______________________________________________ Relationship_______________________</div> <div> Name______________________________________________ Relationship_______________________</div> <div> Name______________________________________________ Relationship_______________________</div> <div> Name______________________________________________ Relationship_______________________</div> <div> Name______________________________________________ Relationship_______________________</div> <div> Name______________________________________________ Relationship_______________________</div> <bR> <div> <B>Commitment To Treatment Statement</B></div> <div> I agree to make a commitment to the treatment process. I understand that this means I have agreed to be actively involved in all aspects of treatment, including: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">attending sessions (or giving Wes at least 24 hours notice when I cannot be present). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">voicing my opinions, thoughts, and feeling honestly and openly, whether negative or positive. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Being actively involved during sessions </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">engaging in experiments outside of therapy if and when they are recommended. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">experimenting with new behaviors and new ways of doing things. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Taking medications, if prescribed by a medical doctor, as they are prescribed (and discussing any ideas for changing meds with the doctor). </div> <bR> <div> I also understand that, to a large degree, my progress depends on the amount of energy and effort I make. If it is not working, I'll discuss it with you. In short, I make a commitment to living a full and meaningful life. </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="6" CELLSPACING="1" WIDTH="719" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFCCFF HEIGHT= 115 WIDTH="699"><div> <I><B>I have read the policies and procedures and I am willing to work with Wes accordingly. I have carefully considered the commitment to treatment statement and I am willing to make this commitment as the statement stands or based on amendments that Wes and I have mutually agreed upon. </B></I></div> <bR> <div> <B>Signature______________________________________________Date__________________________ </B></div> </tD> </tR> </TABLE></div> <bR> </td> </tr></table></body>