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Family Institute, P.C.
Supporting the Family

 

Quick Access

    -Intake Forms
       (forms may not be up to date)
    -CoDA Registration
    -Prepare Registration
    -Make Payment
    -Calendar
    -Privacy Policy


Codependency Wkshp:

   Codependency and
     Boundaries Weekend:
        Minimum = 6; Limit =12
        $200 per person
 -Upcoming Workshop Dates: 
    -Call  503-601-5400
    -July 14-15, 2012
     **CoDA Registration**
          **Area Motels**
 
   Portland Area CoDA Mtgs

Call - Appointments
 
     
   503-601-5400
   503-601-5410 Fax

Prepare/Enrich Tng:
 
 
     -Phone:  for 2012 dates
     -PREPARE Registration

Directions to FG: 
  
     -From Portland
     -Directions from Salem

 Practitioners:
Licensed MH Professionals:
   -Linda Beldin-Korter, LCSW
   -Simona Borza, PMHNP
   -Joe Cereghino, Psy.D.
   -John Crippen, LMFT
   -Bob Davidson, LMFT
   -Wendy Galambos, LPC
   -Heidi Hart, PMHNP
   -Naomi Hunsaker, LPC
   -Brooke Miller, LCSW 
   -Kathy Hardie-Williams, LPC
Registered Interns:   
 
Grad Students:
   -Audrey Spencer, ASU
   -Pam Beck, GFU

 Resources/Links:  
   Foundation Seminars
   Life Renewal Institute
   Love Takes Time
   Self-Injury  
   Sexual Addiction
   SexHelp.com  
   Sexual Anorexia
   The Bridge to Recovery -KY
   Recovery Resources
   Marriage Counseling Blog
   Marriage Friendly Therapist
   Am Assoc for Marriage
       and Family Therapists
   LMFT Therapist Locator
      
   Edwin Noyes, MD, MPH
     "Exposing Spiritualistic
     Deceptions in Health and
     Healing."  Book resource
 
Therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Intake Forms

It would be helpful to have all forms filled out before therapy begins.  The forms are created in Acrobat Reader format.  If you do not have that program, you may download that program free.  If you have problems downloading any of the files in Acrobat, you are probably using an older version, like 4.0.  Most the forms are in version 5.  Click on the Acrobat Reader icon to get the latest version of Acrobat Reader.

You can fill out the forms on your computer, then print them out However, you do not have to fill the forms out on the computer.  You can send the forms directly to your printer.  The Instruction Checklist would be helpful for you to print out and use as a guide. 

Intake Forms for

Bob, Wendy, Joe, John, Naomi, Heidi, Pam, Kathy, Teresa

Intake Forms for

Audrey Spencer

Other Forms

for all clinicians

Handouts

for all clinicians

Contract Contract Release of Confidentiality PR Brochure
Intake Form Intake Form Child Intake Form  
BioPsychoSocial History BioPsychoSocial History Couple: 3 Questions What You Should Know
Managed Care Notice   Couple Questionaire  
    Privacy Policy  
       

   The above and below are Related Forms and Handouts: (forms, links might not be up-to-date)

Bob's
 -Form:
 

  -Couple Agreement

  -Couple/Family Therapy Contract

  -All couples need to evaluate and sign if interested
  -Must be signed for any couple therapy or family therapy
 -Handouts:

  -Curriculum Vitae

  -Professional Disclosure Statement

  -For your information
  -Please print out and read, A must for all clients
Joe's

 -Forms:

 -Handouts:

  -Couple Agreement
  -Couple/Family Therapy Contract
  -Resume
  -Professional Disclosure Statement
  -All couples need to evaluate and sign if interested
  -Must be signed for any couple therapy or family therapy
  -For your information
  -Please print out and read, A must for all clients
Naomi's

 -Forms:

 -Handouts:

  -Couple Agreement
  -Couple/Family Therapy Contract
  -Resume
  -Professional Disclosure Statement
  -All couples need to evaluate and sign if interested
  -Must be signed for any couple therapy or family therapy
  -For your information
  -Please print out and read, A must for all clients
John's

 -Forms

 -Handouts

  -Couple Agreement
  -Couple/Family Therapy Contract
  -Resume
  -Professional Disclosure Statement
  -All couples need to evaluate and sign if interested
  -Must be signed for any couple therapy or family therapy
  -For your information
  -Please print out and read, A must for all clients
Heidi's

Pam's

 -Forms:

 -Handouts:

  -DBT Diary Card
  -Professional Disclosure Statement
  -For Bi-Polar clients
  -Please print out and read, A must for all clients
Wendy's  -Forms:

-Handouts:

  -Couple Agreement
  -Couple/Family Therapy Contract
  -Resume
  -Professional Disclosure Statement
  -All couples need to evaluate and sign if interested
  -Must be signed for any couple therapy or family therapy
  -For your information
  -Please print out and read, A must for all clients
 
 
Instruction Checklist Print this out.  It will help explain which forms you need.
    Contract Everyone must sign and date. Print second copy for yourself.  Click on contract under desired therapist because contracts are different.  If you have questions about the contract, you may raise them with the therapist at your first session (or for that matter, any time).
    Intake Form A must for all new clients to fill out.  One form per family, designating the identified patient (IP) for billing purposes.  If you phone, this information is gathered by the office staff or therapist.
    BioPsychoSocial History This may take up to 1 minute to download, per page (4 pages).  This history is very helpful and will save the therapist a lot of time, reserving the therapy session for discussion and conversation about the presenting problem and your needs.  If marital, both need to fill out this form.
    Medical History Each person fill out.  This information is helpful to make sure that we are treating the whole person. 
    HMO Worksheet This Insurance Verification Form is for your assistance to help you find out your insurance coverage.  There are suggested questions that you could ask and helpful things that you need to know when dealing with your HMO.
Handouts:       
    Managed Care Notice Insurance Clients:  Read, Information about insurance billing and confidentiality.
    Professional Disclosure
    Statement
Each counselor is required to provide this statement about themselves.  please read and printout for your information.   Print out the one on your counselor.
    PR Brochure/Flier This is our brochure that you may print out.  Share with a friend.  This tells more about us.  Our graduate student has a separate flier. 
    What You Should Know "What You Should Know About Marital and Family Therapy" Handout
Additional Forms:  
    Release of Confidentiality For sharing records and/or treatment goals and outcomes between counselors, lawyers, pastors, teachers, non-custodial parent, etc.
    Child Intake Form Four pages, parent fills out on child's behavior, desired changes, problem areas, etc.  Form can be typed, then printed out or printed out and then filled in.  This form is if the child is the identified client.
    Couple: 3 Questions These three questions are most helpful when you come in as a couple.  Each spouse fills one out.  This form will help you get your thoughts organized and clarify what your needs are in the relationship. 
    Couple: Questionnaire These questions might be helpful to clarify your thinking as a couple.  If you desire, fill out and answer the questions that you think are significant and important.  Fax ahead of session or bring to your next session. 
    Couple Agreement When couple come in for therapy, they find this agreement helpful.  It is an agreement between the couple that they want their therapy to remain confidential under all circumstances.  Print out the one with your counselor. 
    DBT Diary Card For those attending the DBT Class.