Christian
Counseling Services
2452 Lacross Court
Lexington, Kentucky 40514
(859) 219-8961–Cell (859) 588-5548
General Information
Christian Counseling Services
Christian Counseling Services is a counseling agency operating with high
standards of training and morality to help those who are seeking peace in the
midst of life’s storms. C.C.S. combines Christian beliefs based on the Holy
Bible with a variety of counseling interventions. The counselor(s) at C.C.S.
believe that true help for life’s problems can only be found through Jesus
Christ. The counselor(s) are God’s instrument in helping clients find this
help.
Your Counselor
Allen Waugh is recognized as a Licensed Professional Clinical Counselor in the
State of
Kentucky
. He has met the requirements of a Master’s Degree in Counseling, a minimum
3,000 hours of counseling, & passing the National Counselor Examination. He
received his Masters Degree in Counseling from
Cincinnati
Bible
College
and Seminary (
Now
Cincinnati
Christian
University
) in May of 1997.
Cincinnati
Bible
College
(
Now
Cincinnati
Christian
University
) is a recognized facility by the State of
Ohio Counseling
and Social Work Board. Mr. Waugh’s counseling is Christian in nature, meaning
that he uses the Bible and prayer extensively in his work. He also combines
other therapeutic interventions which are applicable to Christianity. He
believes that true help only comes through Jesus Christ. Mr. Waugh reserves the
right to refer clients when he deems their counseling needs go beyond that of
his college degree and training. On occasion, Mr. Waugh utilizes the supervision
skills of Dr. Douglas A Spears, LPCC, in
Cincinnati
,
Ohio
.
Counseling
Therapy can last from a few weeks, to several months, and in certain occasions
may continue for years, depending on the needs of the individual. Most people
who make a serious effort find counseling to be helpful Counseling is not
suitable for everyone. Clients must be willing to put forth a concerted effort
to resolve their problem in order for counseling to be successful. Depending on
the nature of the problem, clients should be aware that they could experience
uncomfortable emotions such as anger, fear, and frustration during the course of
their counseling. While your counselor cannot remove these feelings from you, he
will help you work through them ir help you find an alternative counselor.
Fees
C.C.S. seeks to provide counseling for its clients through affordable rates.
Fees based on an individual’s combined income are worked out with the
counselor ahead of time. Payments are to be made at the beginning of each
session. In the event that an individual cannot make payment, he/she should make
the counselor aware “in advance” in order that problems can be worked out.
In the event of checks returned due to insufficient funds, a $15.00 service
charge will be required of the client. A fee schedule and agreement is found on
page three of this document.
Client’s
Rights
Each individual who seeks counseling has certain individual rights afforded to
them. They are:
A. The right to be fully informed about the counselor’s
qualifications, training and
experience.
B. The right to have the counselor available at the appointed
time agreed upon in advance.
C. The
right to question the counselor in regard to his style and method of counseling.
D. The right to discontinue counseling at any time.
Client’s Responsibilities
Each individual who seeks counseling has certain individual responsibilities,
such as:
A. To arrive for the counseling session on time so that the
hour (50 minutes) set aside can
be utilized to the maximum. The amount of time a client is late is deducted from
the
counseling hour. Your counselor does not stay late because you are late. Full
fee is
required even if the client is late for the appointment.
B. To cancel appointments 24 hours in advance (if possible)
so the counselor can plan an
alternative use of his time, or to allow emergency clients the privilege of
being served.
Cancelling within 5 hours of a
scheduled appointment results in charges of half the fee
agreed upon by the counselor and client. Missed appointments (failure to
cancel) result
in payment of the fee in full.
C. If a client misses a scheduled appointment, it is the
client’s responsibility to call and
schedule a new appointment time.
Limits of Confidentiality
A part of the ethics of counseling is to keep all information between counselor
and client confidential. There are certain limits to confidentiality as follows.
A. All therapists are required to provide information
specified by a subpoena issued by a
court of law.
B. The results of treatment or tests must be revealed to a
court, when a client has been
ordered into treatment by the court.
C. A therapist must take steps to protect a client or others
from imminent danger when a
client threatens physical injury to self, others, or the therapist.
D. A therapist must report disclosures of physical or sexual
abuse of a minor to the local
children’s protective service.
E. A therapist must report disclosures of physical abuse of
neglect of an elderly person.
F. Limits of confidentiality are canceled when a therapist is
accused of unprofessional
behavior such as sexual /harassment defamation of character incompetence or
negligence.
G. Limits of confidentiality are canceled when there is a
report or suspected spousal
abuse.
Note: Allen Waugh, LPCC is a Christian counselor who honors the above limits of
confidentiality required by the laws of the State. As a Christian counselor he
believes there is a moral law instituted by God which supersedes the laws of any
state.
I _________________________ (client) have read and had explained the above
paragraphs. I understand that Allen Waugh, LPCC, due his moral standards may at
times feel the need to report information revealed to him to authorities or
other individuals which he (counselor) feels morally obligated to do.
FEE SCHEDULE
Christian Counseling Services
Hourly fees are based on the combined income of each family and are as follows:
Combined Income
$0.00 to
$40,000 $40.00
$40,001 to $45,000
$45.00
$45,001 to $60,000
$60.00
$60,001 to $70,000
$70.00
$70,001 to $80,000
$80.00
$80,001 to $90,000
$90.00
$90,001 to $100.000
$100.00
$100,001 plus
$125.00
My annual combined income is estimated to be ____________.Based on the above fee
schedule,
I agree to pay Allen Waugh, LPCC of Christian Counseling Services the sum of
________ per
counseling hour (50 minutes). In the event that longer appointments need to be
scheduled, the client agrees to pay the portion of the second hour that is
applicable.
_____________________________
____________
Client Signature
Date
_____________________________
____________
Counselor Signature
Date
Information Regarding Additional Charges
Clients of Christian Counseling Services should be aware that charges apply for
any written correspondence to attorney’s doctors, or any others that request
or require information from the counselor. **Clients agree to pay the hourly fee
agreed to in the above section for the following:
1. Any written correspondence, research and copying of
progress notes.
2. The hourly fee of the client will be required for time
incurred for court appearances, or
depositions, or phone calls to
attorneys or doctors, and is required up front.
3. Travel time to the courtroom or place of depositions.
4. Phone calls from the client to the counselor lasting over
15 minutes.
I _________________________ have read the general information pages, had them
explained to me, understand the information presented and agree to enter into
counseling with Christian Counseling Services.
_____________________________
___________
Client Signature
Date
_____________________________
___________
Counselor Signature
Date
PERSONAL DATA
Date
___________________
Name: _____________________
Date of Birth______________
Address: ____________________________________________________________________
(Street)
(City)
(State)
( Zip)
Phone _________________________ Cell Phone #
_________________________
Age ______ Weight _______
Ht. ______ Sex _____ Hair ______
Eyes _____
Occupation _____________________
Hours Per Week _____________
Present Employer _______________________
Phone #___________________
Length of Employment ___________________________
Social Security # _________________________
E-mail _________________________
Marital Status Single _______ Married
___________ Years Married _________
First
Marriage Yes ______ No _______ If no, how
long were you married?_______
Separated ____ Length of time ______
Divorced ______ Length of time _______
Widowed ____ Length of time.
Spouses Name _________________________ Age _____
Employer __________________
Occupation __________________________ Hrs. ____
Phone _____________________
Person’s in your household or significant others:
Name/ Age/ Relationship
Name/ Age/ Relationship
_____________________________
___________________________
_____________________________
___________________________
_____________________________
___________________________
In Case of Emergency Call _______________________ Phone ___________________
PERSONAL DATA (Cont.)
Educational Background (Please give names)
Grade School ________________________
High School ________________________
College ____________________________
Major _____________________________
Post Grad. _________________________
Religious Affiliation __________________________
Congregation __________________________ How long have you attended?
_____________
Hobbies or Special Interests
______________________________________________________________________________
______________________________________________________________________________
Physical Health: Excellent ______ Good ______ Fair
______ Poor ______
Describe any serious illnesses, accidents or operations.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Current Medications: Please list “all” medications you are taking.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Physician: ______________________________ Address ________________________
Allergies of any type _________________________________
What is your current relationship with God? (What do you feel about Him? How
does He feel about you? How close do you feel your are to Him today? How
close do you feel He is to you?)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please state specifically the problems that have caused you to seek counseling.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
How long have these problems persisted? ____________________________________
Have these problems occurred before? __________________
Are you having suicidal thoughts or have you made any attempts on your life?
______________________________________________________________________________
______________________________________________________________________________
If you answered yes to the previous question, when was your last suicidal
thought?
