(Required) Please note, without your email address there is no way for The Cove to respond to your questionnaire.  You must be sure the email address you enter below is accurate.
Email Address:

Agreement and Consent Form

Instructions: Please read the following, fill in the required information,
and click submit. You may also print out this form and mail it to me at:

The Cove Counseling

1105 S State Street
Clearfield, Utah 84111

attn: Vera Christensen, LCSW

Hello. Welcome to The Cove's eTherapy. This Agreement and Consent Form is being provided to you, a client, in order to inform you about Online Therapy and answer some questions you may have.

As a client of The Cove's eTherapy, I understand that online therapy is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither The Cove nor me. Internet availability may be limited or disrupted by things such as server problems, caused by software or hardware malfunction, natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth), and other technical problems beyond the control of The Cove and myself. If something like this were to occur, any scheduled appointments would be re-scheduled at no additional cost.

I understand that I must be at least 18 years of age to consent for services by The Cove (If not, a parent or legal guardian must contact Vera Christensen and provide a written consent for services). As a client of The Cove, I declare that I am free of suicidal thoughts. I also understand that Vera Christensen may be required to violate my confidentiality to make appropriate legal notifications if he reasonably believes I am involved in child abuse or neglect, or if I intend to harm myself, or if I am involved in criminal activity. If a breach of confidentiality were to occur, such actions would be pursuant to the laws of the State of Utah. As a note, the State of Utah does mandate that clinical social workers or other types of mental health clinicians notify authorities when a client makes a threat against another individual.

For all legal and regulatory purposes, the services of The Cove's eTherapy are provided from the State of Utah. I further understand that Vera Christensen is a Licensed Clinical Social Worker in the State of Utah and that she is subject only to the laws and regulations of the state of Utah. Accordingly, Vera Christensen will only be held liable under the Utah Social Work Licensing law and statutes.

I realize that I will be charged the according fees in US Dollars for each session that Vera Christensen spends working with me (unless otherwise stated and mutually agreed upon by Vera Christensen and myself before services are rendered). I need to recognize that during the process of psychotherapy, psychological discomfort may arise (as difficult issues are addressed and worked through). This is an oftentimes necessary part of psychotherapy, even though it does not guarantee resolution of any kind or assure success for therapy, either explicit or implied. This means that there is no guarantee as to the outcome from the services of The Cove eTherapy. This includes limitation or restriction, of any guarantee, for information, counseling, uninterrupted access, and other services provided through The Cove eTherapy. In addition, as a client of The Cove, I can end services at any time, for any reason, without prior notification or explanation to The Cove. (Although a note explaining any decision to stop services would be greatly appreciated).

I also acknowledge that, although The Cove eTherapy has taken a significant number of steps to ensure the confidentiality of Online communication, these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify The Cove and Vera Christensen from all suits, claims, and other actions originating from psychotherapy provided through The Cove eTherapy.

 

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Optional Questionnaire

The following information is being collected for professional purposes only. Responding to questions is voluntary. Confidentiality of all submitted information will be strictly maintained; the details you supply will not be released to anyone other than as mandated by law.

All questions are optional .We use a wonderful service to securely send your information to us. If you would rather not send this information via the internet, please print the questionnaire and fax it to our private fax number at (801) prior to your e-therapy appointment.

Please answer as many questions as you are comfortable responding to.

 

Name
Gender	Select Male Female
Age
Marital Status	Select Married Divorced Separated Single Widowed Domestic Partner
Occupation
Employment Status	Select Full-time Part-time Unemployed Retired
Education Level	Select GED High School degree Some college College degree Graduate degree Post Graduate degree Professional degree

Please briefly describe the problem(s) that you would like to discuss or work through:

How severe would you rate your symptoms?
Select Mild Moderate Severe

Are you currently getting treatment from a mental health professional?
Yes  No

If yes, please explain:

 

In the past, have you been treated by a mental health professional ?
Yes No

If yes, for what?

 

What was the outcome?

 

Are you currently taking any psychotropic medication(s)? (e.g. anti-depressants or anti-anxiety medication)
Yes No

 

If yes, please list:

Have you taken any psychotropic medication(s) in the past?
Yes  No

How would rate the frequency of your alcohol intake?
Select Never Rare Occasional Frequent Heavy I don't know

What type of nicotine products do you use?
Select None Cigarettes Smokeless tobacco Cigars Other

Do you use "recreational drugs"?
Yes  No

 

If yes, please list:

 

How would you rate your overall health?
Select Below average Average Above average Excellent I don't know

Do you have any medical problems that you think contribute to your present situation?
Yes  No

If so, please briefly describe.

Enter any other comments here