Please take a moment to read, fill out and sign the following: CLIENT INTAKE, NOTICE OF CLIENT CONFIDENTIALITY, CONSENT FOR TREATMENT, and NOTICE OF PRIVACY PRACTICES. Sign the bottom to agree to all four documents.

CLIENT INTAKE

Please provide the following information and answer the questions below. When not applicable, please put "N/A." Please note: information you provide here is protected as confidential.

Client Full Name:

Preferred Name: Birth Date:

Name of parent/guardian (if under 18 years):

Marital Status: Never Married Domestic Partnership Married Separated Divorced Widowed

Please list any children and their ages:

Address:

(City) (State) (Zip)

Home Phone: May we leave a message?YesNo

Cell/Other Phone: May we leave a message? Yes No

E-mail: May we email you? Yes No

Emergency Contact: Phone:

How were you referred to us: Is there any additional information PathLight Counseling should know about you?

GENERAL HEALTH AND MENTAL HEALTH INFORMATION:

Have you previously received any type of mental health services (therapy, psychiatric services, etc.)? Yes No

If yes, previous therapist/practitioner(s) and dates:

Are you currently taking any prescription medication? Yes No

Please list:

Have you ever been prescribed psychiatric medication? Yes No

If yes, Please list and provide dates:

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise to you participate in?

Please list any difficulties you experience with your appetite or eating patterns:

Are you currently experiencing overwhelming sadness, grief, or depression? Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panic attacks, or do you have any phobias? Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain? Yes No

If yes, please describe:

Do you drink alcohol more than once a week? Yes No
How often do you engage recreational drug use? Daily Weekly Monthly Infrequently Never
Are you currently in a romantic relationship? Yes No

If yes, for how long?

On a scale of 1-10 (1=unhealthy/unsatisfying; 10=healthy/satisfying) how would you rate your relationship? Why?

What significant life changes or stressful events have you experienced recently:

FAMILY MENTAL HEALTH HISTORY:

In the section below, identify if there is a family history of any of the following. Check all that apply. If checked, please indicate the family member(s) relationship to you in the space provided (father, grandmother, uncle, etc.).

	Check all that apply	Family Member
Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts

ADDITIONAL INFORMATION:

1. Are you currently employed? Yes No
  If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your work or work environment?

1. Do you consider yourself to be spiritual or religious? Yes No
  If yes, describe your faith or belief:

1. What do you consider to be some of your strengths?
2. What do you consider to be some of your weaknesses?
3. What would you like to accomplish through your time in therapy?

I, (client or legal guardian) authorize PathLight Counseling, LLC or any

holder of medical information about me to release to my insurance company or its representative, any information needed concerning the examination or treatment rendered to me that is necessary to process the insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to be paid directly PathLight Counseling, LLC in such amount as my benefits allow. This authorization is effective until terminated in writing by the client or their guardian. Your signature below also indicates that you have read the Consent for Treatment and HIPPA agreement and agree to the terms.

Initial here and sign at the bottom: Parent(s)/Guardian(s)PATIENT (or PARENTS/GUARDIANS, IF PATIENT IS A MINOR)

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY PathLight Counseling, LLC AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. This notice is effective June 1, 2014. It is provided to you pursuant to provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and related federal regulations. If you have questions about this notice please contact Britt Parramore, DIRECTOR, LPC, at 470-249-4499. PATHLIGHT COUNSELING, LLC is a Corporation in the State of Georgia responsible for providing a variety of professional services which deal with mental health and other confidential information. Both federal and state laws establish strict requirements for most programs regarding the disclosure of confidential information, and PATHLIGHT COUNSELING, LLC must comply with those laws. For situations where more stringent disclosure requirements do not apply, this Notice of Privacy Practices describes how PATHLIGHT COUNSELING, LLC may use and disclose any Protected Health Information (PATIENT INFORMATION) for treatment, payment, health care operations, and for certain other purposes. This notice relates only to health information. It describes your rights to access and control any PATIENT INFORMATION, and provides information about your right to make a complaint if you believe PATHLIGHT COUNSELING, LLC has improperly used or disclosed any PATIENT INFORMATION. Protected health information is information that may personally identify you or the child(ren) or minors under your guardianship and relates to any past, present or future physical or mental health condition and related health care services. PATHLIGHT COUNSELING, LLC is required to abide by the terms of this Notice of Privacy Practices, and may change the terms of this notice at any time. A new notice will be effective for all PATIENT INFORMATION that PATHLIGHT COUNSELING, LLC maintains at the time of issuance. Upon request, PATHLIGHT COUNSELING, LLC will provide you with a revised Notice of Privacy Practices by posting copies at its facilities, publication on PATHLIGHT COUNSELING, LLC’s website, in response to a telephone or facsimile request to the DIRECTOR, or in person at any facility where you receive services from PATHLIGHT COUNSELING, LLC.

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Any PATIENT INFORMATION may be used and disclosed by PATHLIGHT COUNSELING LLC, its’ employees, contractors, agents and attorneys for the purpose of providing mental health services to you. Protected health information is routinely needed in order to ensure proper mental health treatment.

Treatment: Any PATIENT INFORMATION may be used to provide, coordinate, or manage you or your child’s mental health services, including coordination with a third party that has your permission to have access to any PATIENT INFORMATION, such as other health care professionals who may be treating you or your child(ren), a health care specialist or laboratory.

Payment: Your PATIENT INFORMATION or that of your child(ren) may be used to obtain payment for yours or your child(ren)’s health care services.

Health Care Operations: PATHLIGHT COUNSELING, LLC may use or disclose any PATIENT INFORMATION to support the business activities of PATHLIGHT COUNSELING, LLC including, but not limited to, quality assessment activities, employee review activities, training, licensing, and other business activities. PATHLIGHT COUNSELING, LLC may use a sign-in sheet at the registration desk at any facility or office where services are provided. You may be asked to provide your name and other necessary information, and you may be called by name in the waiting room when a staff member is ready to see you, and any PATIENT INFORMATION may be used to contact you about appointments and/or for other operational reasons. Any may be shared with third party “business associates” who perform various activities that assist us in the provision of yours or your child(ren)’s mental health services.

Other uses and disclosures of any patient information will be made only with your written authorization, which you may revoke in writing at any time, except as permitted or required by law as described below.

Other Permitted or Required Uses and Disclosures with Your Authorization or Opportunity to Object The Department may use and/or disclose any information to a court of law, to a family member, relative or any other persons you identify on the PATHLIGHT COUNSELING, LLC Authorization Form. You have the opportunity to agree or object to the use and/or disclosure of all or part of any patient information Permitted or Required Uses and Disclosures without Your Authorization or Opportunity to Object PATHLIGHT COUNSELING, LLC may use or disclose any patient information without your authorization when required to do so by law; for public health purposes, to a person who may be at risk of contracting a communicable disease, to a health oversight agency, to an authority authorized to receive reports of abuse or neglect, in certain legal proceedings, and for certain law enforcement purposes. Protected health information may also be disclosed without your authorization to a coroner, medical examiner, or funeral director for certain approved research purposes, to prevent or lessen a threat to health or safety, and to law enforcement authorities for identification or apprehension of an individual.

Required Uses and Disclosures: Under the law, PATHLIGHT COUNSELING, LLC must make disclosures to you, when required by the Secretary of the Department of Health and Human Services and to investigate or determine the Department's compliance with the requirements of the Privacy Rule at 45 CFR Sections 164.500 et.seq.

2. YOUR RIGHTS UNDER THE FEDERAL PRIVACY RULE

The following is a statement of your rights with respect to any PATIENT INFORMATION and a brief description of how you may exercise these rights:

a. You have the right to inspect and copy your protected health information. Upon written request, you may inspect and obtain a copy of any PATIENT INFORMATION for as long as the Department maintains the PATIENT INFORMATION. A reasonable, cost-based fee for copying, postage and labor expense may apply. Under federal law you may not inspect or copy information compiled in anticipation of, or for use in, a civil, criminal, or administrative proceeding, or PATIENT INFORMATION that is subject to a federal or state law prohibiting access to such information.

b. You have the right to request restriction of your protected health information. You may ask in writing that PATHLIGHT COUNSELING, LLC not use or disclose any part of any PATIENT INFORMATION for the purposes of treatment, payment, or healthcare operations, and not to disclose PATIENT INFORMATION to family members or friends who may be involved in your care. Such a request must state the specific restriction requested and to whom you want the restriction to apply. PATHLIGHT COUNSELING, LLC is not required to agree to a restriction you request, and if PATHLIGHT COUNSELING, LLC believes it is in your best interest to permit use and disclosure of any PATIENT INFORMATION, the PATIENT INFORMATION will not be restricted, except as required by law. If PATHLIGHT COUNSELING, LLC does agree to the requested restriction, PATHLIGHT COUNSELING, LLC may not use or disclose any PATIENT INFORMATION in violation of that restriction unless it is needed to provide emergency treatment.

c. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. Upon written request, PATHLIGHT COUNSELING, LLC will accommodate reasonable requests for alternative means for the communication of confidential information, but may condition this accommodation upon your provision of an alternative address or other method of contact. PATHLIGHT COUNSELING, LLC will not request an explanation from you as to the basis for the request.

d. You may have the right to request amendment of any protected health information. If PATHLIGHT COUNSELING, LLC created any PATIENT INFORMATION, you may request in writing an amendment of that information for as long as it is maintained by PATHLIGHT COUNSELING, LLC. PATHLIGHT COUNSELING LLC may deny your request for an amendment, and if it does so will provide information as to any further rights you may have with respect to such denial.

e. You have the right to receive an accounting of certain disclosures PATHLIGHT COUNSELING, LLC has made of any protected health information.

This right applies only to disclosures for purposes other than treatment, payment, or healthcare operations, excluding any disclosures PATHLIGHT COUNSELING, LLC made to you, to family members or friends involved in your care, or for national security, intelligence, or notification purposes. Upon written request, you have the right to receive legally specified information regarding disclosures occurring after April 14, 2003, subject to certain exceptions, restrictions, and limitations.

3. You have the right to obtain a paper copy of this notice from PATHLIGHT COUNSELING, LLC.

4. COMPLAINTS RELATED TO USE OR DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION OR RIGHTS

You may complain to PATHLIGHT COUNSELING, LLC and to the Secretary of Health and Human Services if you believe your health information privacy rights have been violated. You may file a complaint, in writing, with PATHLIGHT COUNSELING, LLC which maintains any PATIENT INFORMATION. You must state the basis for your complaint. PATHLIGHT COUNSELING, LLC will not retaliate against you for filing a complaint. You may contact Britt Parramore, DIRECTOR, LPC, at 470-249-44995 or by email to Attn: Britt Parramore, DIRECTOR, LPC, PATHLIGHT COUNSELING, LLC, at britt@pathlightga.com for further information about the complaint process, this notice, or your rights set forth above. Please sign a copy of this Notice of Privacy Practices for PATHLIGHT COUNSELING, LLC’s records.

I have read this Notice on the date indicated below.

June 24, 2025

Initial here and sign at the bottom: Parent(s)/Guardian(s)PATIENT (or PARENTS/GUARDIANS, IF PATIENT IS A MINOR)

CONSENT FOR TREATMENT

I voluntarily agree to receive a mental health and medical health assessment, substance use disorder treatment, co-occurring disorders treatment, and discharge/aftercare planning by the staff of PathLight Counseling to take place primarily on the grounds of the facility located at 4390 Earney Rd, Suite 140, Woodstock, GA 30188.

I understand and agree that I will participate in my treatment plan, and that I may discontinue treatment and/or withdraw my consent for treatment at any time.

NOTE: All information developed during the course of my treatment is Protected Health Information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule. PathLight Counseling is a covered entity of this rule.

I have read this Notice on the date indicated below.

June 24, 2025

Initial here and sign at the bottom: Parent(s)/Guardian(s)PATIENT (or PARENTS/GUARDIANS, IF PATIENT IS A MINOR)

NOTICE OF CLIENT CONFIDENTIALITY of Alcohol/Drug Abuse and Mental Health Client Records

Federal laws and regulations protect the confidentiality of alcohol/drug abuse and mental health client records maintained by PathLight Counseling. Generally, PathLight Counseling may not say to a person outside the program that a client attends the program, or disclose any information identifying a client as an alcohol or drug abuser, unless:

1. The client consents in writing.
2. The disclosure is allowed by a court order.
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal regulations. Federal laws and regulations do not protect any information about a crime committed by a client either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities.

(See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR part 2 for regulations)

June 24, 2025

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May 27, 2025 2:02 pm -02

CLIENT PACKAGE Uploaded by Britt Parramore - info@pathlightga.com IP 162.239.100.54