Agreement and Questionnaire

Email Address: *

Agreement and Consent Form

Instructions: Please read the following, fill in the required information, and click submit.

Hello. Welcome to Empowerment Therapy Online at www.empowermenttherapy.com. 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. But it is highly recommended that you read the FAQ's section, as well as other informational sections to acquire more details about my services, my qualifications and the most effective and efficient procedure in obtaining these services. Please read the following agreement narrative as well as the Questionnaire items very carefully as the agreement is an integral part of the initial questionnaire that you submit:

As a client of Brian J. Hubbard LICSW, BCD,at Empowerment Therapy Online, I understand that online therapy is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither Brian J. Hubbard, LICSW 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 Brian J. Hubbard, LICSW and myself. If something like this were to occur, and a telephone appointment had been scheduled, any scheduled appointments will be re-scheduled at no additional cost.    If any of the disruptions described above that are beyond the control of Brian J. Hubbard and myself, it is my responsibility to resend the message within a 24-48 hour period so the sender will know that the message has been received  In fact,it is my responsibility to click on the 'received' button whenever I do receive a message from Brian J. Hubbard .  The e-mail message needs only to contain the words ‘message received’ on the subject line to confirm that a message has been received. This will ensure that the message has been received and no connectivity problem exists. Whenever Brian J. Hubbard sends a message, an automated request notifying the recipient of the message has the option of sending an automated reply to confirm that the message has been received. Again,  I understand that I am required to send the auto reply so that Brian J. Hubbard will have confirmation that the message has been received.  Any complication, delay or other problem arising from the refusal to send the auto-reply is not the fault of Brian J. Hubbard .

Also, each message sent by Brian J. Hubbard, LICSW from www.empowermenttherapy.com will contain the following text at the end of the message:

**********************************************************************

This message is intended only for the designated recipient(s).  It may contain confidential or proprietary information and may be subject to the attorney-client privilege or other confidentiality protections.

If you are not a designated recipient, you may not review, use, copy or distribute this message.  If you receive this in error, please notify the sender by reply e-mail and delete this message.  Thank you.

[Despite this protection by warning unintended recipients not to read the messages and to delete them immediately, it is much more preferable, of course, that such an error does not occur. This is why it is so important that you provide your e-mail address with precise accuracy; Brian J. Hubbard, LICSW can not be held responsible for messages being sent to erroneous places if the wrong e-mail address is provided. In fact, it is highly recommended that you send a preliminary e-mail to brian@Empowerment Therapy.com as a test to ensure that you have provided your accurate e-mail address].

I understand that I must be at least 18 years of age to consent for services by Brian J. Hubbard, LICSW (If not, a parent or legal guardian must contact Brian J. Hubbard and provide a written consent for services). As a client of Brian J. Hubbard, LICSW at www.empowermenttherapy.com, I declare that I am free of suicidal and/or homicidal thoughts and/or intentions. I also understand that Brian J. Hubbard, LICSW may be required by state law 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. This is discussed in more detail on the Confidentiality and FAQ's sections of www.empowermenttherapy.com. If a breach of confidentiality were to occur, such actions would be pursuant to the laws of the State of Rhode Island. As a note, the State of Rhode Island does not mandate that clinical social workers or other types of mental health clinicians notify authorities when a client makes a threat against another individual, UNLESS that threat is professionally assessed to be serious in intent, has a thought out plan and the client presents a psychological demeanor and/or profile that reflects obvious poor judgment, poor impulse control, rage and/or hopelessness.

For all legal and regulatory purposes, the services of Brian J. Hubbard, LICSW are provided from the State of Rhode Island. I further understand that Brian J. Hubbard, LICSW is a Licensed Independent Clinical Social Worker-Advanced Clinical Practitioner (LICSW) in the state of Rhode Island as well as Massachusetts and that he is subject only to the laws and regulations of the state of Rhode Island where his venue of practice is located. Accordingly, Brian J. Hubbard, LICSW will only be held liable under the Rhode Island Social Work Licensing law and statutes.

I realize that I will be charged $20.00 US Dollars for each 15 minutes of time  that Brian J. Hubbard, LICSW spends working with me (unless otherwise stated and mutually agreed upon by Brian J. Hubbard 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 often times 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 Brian J. Hubbard a successful outcome also depends on the constructive, active participation of myself. In addition, as a client of Brian J. Hubbard, LICSW , I can end services at any time, for any reason, without prior notification or explanation to Brian J. Hubbard, LICSW at www.empowermenttherapy.com. (Although a note explaining any decision to stop services would be greatly appreciated and very likely a major therapeutic advantage).

I also acknowledge that, although Brian J. Hubbard, LICSW 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 Brian J. Hubbard, LICSW from all suits, claims, and other actions originating from psychotherapy provided through Brian J. Hubbard, LICSW .

Optional Questionnaire

The following information is being collected for professional purposes only. Responding to questions is voluntary, but very strongly encouraged, especially the items with star(*). 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 or your written request and signed consent.

All questions are optional. However, please understand that the more information you supply, the more I will be able to help and the more cost-effective therapy will be. In fact, if the items that have a star (*) are not answered, it is likely that I will not be able to help very much. A very important part of therapy is the bond between the therapist and client, and the major cornerstone of this bond is trust, so it is important to consider the risk of trusting someone who wants to help you so progress in therapy may occur. Again, the more questions you answer will save you money as less clarification - and time - will be necessary. In fact, I suggest that if you don't answer the majority of the questions (preferably all of them), especially those with a star (*), you may want to wait until you are ready to answer these questions. I realize for some that this encouragement may be an anxiety-provoking situation, but this is the hallmark of what successful therapy is all about - taking the leap of faith by trusting a professional who has dedicated his life to helping others and give him a chance to help you.

Name:
Gender:	- choose - Male Female
Age :*
Marital Status:*	- choose - Single Married Divorced Separated Domestic Partner Other
Occupation:*
Employment Status:*	- choose - Employed Full-Time Employed Part-Time Unemployed Retired Retired-Medical Disability Other
If more than one of the above apply (e.g. retired and working part-time),please describe:*
Education Level:*	- choose - Secondary Education GED High School Bachelor's Degree Master's Degree Doctoral Degree Special School/Education
It is interesting to know about educational background, so please briefly describe.
*Who referred you to me? - choose - A Friend/Relative A Mental Health Professional A Medical Professional A Community-Based Agency A Hospital/Inpatient Facility Other If Other, please describe. If you referred yourself, how did you find me: - choose - Internet Search Advertisement Article Speech Other If Other, please describe. If you did an Internet search, can you recall the keywords you used? If someone else referred you, can you describe, if possible, how they were aware of me?
Please describe the problem(s) as clearly as possible that you would like to discuss or work through:(this is perhaps the most important question on the questionnaire, so please describe as best as you can, but relatively briefly.)**
Please describe what steps you have taken to deal with this problem.
Is there a reason you are seeking services at this present time? (It can be assumed that the problem you reported in the previous item has been persisting at least for a little time, and it would be clinically significant to respond to 'why now?')**
How severe would you rate your symptoms?* - choose - Mild Moderate Severe Very Severe
What is the level of depression you feel?* - choose - Normal Mild Moderately Severely Extremely
What is the level of anxiety you feel?* - choose - Normal Mild Moderately Severely Extremely
What is the level of the general combination of anxiety and depression?* - choose - Normal Mild Moderately Severely Extremely
For any of the depression and anxiety questions above, please describe below as best as you can the characteristics (e.g. frequency of episode, usual time of episodes, circumstances associated, associated thoughts):*
Are you dealing with obsessive thoughts and/or compulsive behaviors?* - choose - Yes No If yes, please describe* :
Are you having troublesome and recurring thoughts that concern you?* - choose - Yes No If yes, please describe(may be more than one):* :
Are you having problematic behaviors not listed above that concern you?* - choose - Yes No If yes, please describe(may be more than one):*
Are you having any sleep disturbances?* - choose - Yes No If yes, please describe(e.g. getting to sleep, waking up too early and falling back asleep and circumstances associated with these problems):*
Are you having any generalized appetite problems (weight gain, weight loss or general gastric disturbances including vomiting, diarrhea, heartburn, nausea?)* - choose - Yes No If yes, please describe:*
Are you currently getting treatment from a mental health professional?* - choose - Yes No If yes, please explain:
In the past, have you been treated by a mental health professional? - choose - 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)? - choose - Yes No If yes, please list:
Have you taken any psychotropic medication(s) in the past? - choose - Yes No
How would you rate the frequency of your alcohol intake? - choose - None Light Moderate Heavy Alcohol Addicted
How would you rate your nicotine intake? - choose - None Light Moderate Heavy
Do you use "recreational drugs"? - choose - Yes No If yes, please list:
*How would you rate your overall health? - choose - Poor Fair Moderately Healthy Good Health Excellent Health
*Do you have any medical problems that you think contribute to your present situation? - choose - Yes No If yes, please briefly describe.
**Do you or someone close to you have a permanent physical disability or a chronic medical illness listed below that you have difficulty coping with and would benefit from Empowerment Therapy?  - choose - None Blindness/visual impairment Deafness/hearing impairment Deaf/blind(hearing/visually impaired) Mobility impairment/spinal cord injury Multiple sclerosis Muscular Dystrophy Amputation Severe Arthritis Organic mental disability/CP Traumatic brain injury Diabetes Cardiac/circulatory problems Parkinson's Disease Renal/kidney Hepatitis Auto-immune disease Lung disease Cancer Physical disfigurement Burn victim Scoliosis Gastrointestinal-colostomy Developmental Disability Upper GI Other
If 'Other',please identify:
If not yourself, please identify.
*Have you experienced one of the following significant or traumatic losses that is difficult to cope with and you could benefit from Empowerment Therapy?   - choose - Loss of loved one Divorce Loss of job Loss of home Loss of financial security Traumatic Accident Emotional Abuse Rape Natural conditions (e.g. earthquake, hurricane, tsunami, volcano eruption,flood, blizzard) War/battle shock/combat-related PTSD Terrorism/gang violence/other acts of violence Homicide/violent act with relative and/or friend(pre-meditated or otherwise) Other Not Applicable
If other, please describe briefly.*
*If you have experienced each of the two categories (disability/chronic illness and traumatic loss) please briefly describe:
*Enter any other comments here that you feel to be important and related to your seeking therapy:
Do you desire specialized Empowerment Therapy (designed for individuals and families/friends of those dealing with significant losses and requires a minimum of 90 minutes)? - choose - Yes No