Client History Form

Please download  this intake form and fill out and bring to your first session with Jennie Kristel. Thank you!

 

Date______________ How did you hear about us? _____________
Name:___________________________ Home phone:____________

Home Address: __________________________________________

Occupation: ____________________________________________

Company Name and address: ________________________________________________________________
Work Phone_______________

There may be times I need to call you to cancel or postpone an appointment. Is it ok to leave a message about this at home? _______ Work? _______________
Birth date: ______________ Age: __ Marital status_________ Children? (If yes, state ages)_________________

List reasons for seeking counseling now: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Birth History:
Tell what you understand about the circumstances around your birth:
What kind of delivery was it?

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Were you breast or bottle fed?_______________________________

Are you oldest, youngest? Middle? __________________________________________

Adopted? ____________________________________________________________________________________________________________________________________________________________
Were you or are you in foster care?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Siblings? Ages and birth order:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Emergency contact person_______________ Phone: _____________

Who is your personal physician? ________________________________

How would you rate your present state of health?___________________

List current health problems: _________________________________________________________________________________________________________

Please List areas on physical level that you are experiencing discomfort and/or pain.__________________________________________________________________________
________________________________________________________________________________________________________________________________________________

When did this begin? ________________________

Do you have any on going mental health concerns? If yes, please describe (Use back of page if necessary)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list all medications that you are taking (Use back of page if necessary)_______________________________________________________________________________________________________________________________________________________________________________________________________________
Please list all hospitalizations, including psychiatric, dates, location, and briefly, the reasons: Please use separate page if necessary. (Use second page if necessary)
__________________________________________________________________________________________________________________________________________________________________________________________

Please list previous counseling experiences. Was it positive? Negative?_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What is your relationship with your creativity? How do you feel about doing art?
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Religion by upbringing: ___________________ Current religion or spiritual path
________________________________________________________________________________________________________________________________________________
Length of sessions: 60-75 minutes

Fee: (Individual): $75.00 (Couples) $120.00 per session, paid at the time of session. Individual needs are taken into account, and so it is encouraged for you to talk to me about your financial needs during the interview.

Confidentiality:
As a rule, all information shared in sessions is confidential. Information about sessions will not be shared without your permission (except for confidential professional case supervision where no identifying information is disclosed).

Limitations to Confidentiality: If a client is judged to be in immediate danger of injuring him/herself or someone else all the necessary steps will be taken to assist and protect the client or others. This includes contact and disclosure with others.

Vermont state law requires that psychotherapists report to Social Rehabilitation Services any “reasonable suspicion” of physical, emotional or sexual abuse of minors.

Since our community is so small, we may inadvertently see each other outside sessions. Some people have concerns about this. If you have specific requests about how I should or shouldn’t greet you, please let me know in our initial session. Otherwise I will try to mirror your greeting or absence of greeting.

In the unusual circumstance of a court order, to release information, I am required to comply.

Canceling sessions: I request a 24 hour notice of cancellation, except for emergencies. The charge for missed sessions is the cost of your session determined in the initial session.

The Process of Therapy:

Though there can be no guarantees about therapy outcome, therapy does take consistent effort to attain maximum benefits. It’s important to note that strong feelings, changes in close relationships, and the re-experiencing of memories may be part of this process. Please let me know if you experience any problems with any aspect of therapy. This is very important information.

The form of therapy that is used in this office is highly integrated body-mind and creative therapies. My style is to use what works for each individual. This maybe Narrative verbal therapy, Reiki, a form of Japanese energy work, Focusing, and the different creative arts.

It is important for me as your therapist to know what works for you, and we will do this through exploration. This is a co-creative process, in which you are working in your own healing.
I have read and understood these notes.
_________________________________
Guardian or parent (if client is a minor)

__________________________________
Date Client signature

Jennie Kristel, MA, REAT, RMT, APTT
JourneyWorks
1205 North Avenue, Burlington, Vermont 05408
802-860-6203 http://www.journeyworksvt.com

Informed Consent

I received my B.S. double majoring in Psychology and Interpersonal Communications with a minor in Theatre Education from Emerson College in 1984; a Masters in Expressive Therapies from Lesley University in 1986, and an advanced certificate in Spiritual ecology, from the Institute of Culture and Creation Spirituality in 1992. I studied Focusing and Spiritual Direction while there. I have over 800 hours in training in Psychodrama, having studied with Peter Rowan, at the New England Institute of Psychodrama, Jonathan Fox with the Northeast Triangle School of Psychodrama and Rebecca Walters and Judy Swallow with Hudson River Psychodrama Institute. I studied at the School of Playback Theatre and received a diploma in 1995, and was accredited as a trainer in 2014. I am credentialed as a Registered Expressive Arts Therapist, with the International Expressive Arts Therapy Association. I have worked with Adolescences in crises, Adult Day Treatment programs, and with homeless adults in crises, Hospice care, postpartum care and counseling, and with women who have experienced domestic and sexual abuse. My philosophy stems from deep understanding of Jungian thought, and Humanistic Person Centered theories. In recent years, I have been studying and using Narrative Therapy. I teach courses related to expressive therapies and energy work at Burlington College, and also in South Asia where I work with local NGO’s and universities. I have been in private practice since 2001. I am rostered as a non certified, non licensed psychotherapist in the State of Vermont. My rostered number is # 0970000791. I am in a monthly supervision consultation group.

Confidentiality
Burlington is a small community. There may be times that we see each other on the street, or at a gathering space. As a matter of course, I will not say anything or signal I know you, unless you approach me first. This is to protect and respect your confidentiality. In the event of suspected harm and/or self harm, I am required, by law to suspend confidentiality as it pertains to the safety of the client and/or myself.

My Private Practice Social Media Policy
Please read it to understand how I conduct myself on the Internet as a mental health professional and how you can expect me to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, I encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when I need to update this policy. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy.

Friending
I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
I have read and understood these notes.

________________________________________________________________________
Guardian or parent (if client is a minor) Date Client signature

Jennie Kristel, M.A. REAT, RMT APTT 1205 North Avenue
Master Reiki Practitioner Burlington, VT.05408
Expressive Therapist 802-860-6203
I, _____________________________, apply and give consent for treatment using the Reiki method and Focusing, a model developed by Eugene Gendlin. I understand that the sessions may (but do not have to) involve touch and gentle movement and are conducted with the client clothed, lying down, sitting or moving.

 I understand that during the course of my therapy there may be sessions when there is no touch or movement in the session. This may occur when either Jen Kristel or I decide that traditional talk therapy or a creative arts based therapy is more appropriate for that session or when one of us prefers to not use touch for physical or emotional reasons.

 I know of no physical or emotional reasons why Reiki and/or Focusing would be inappropriate to include in my therapy. I understand that I may stop a session at any time. I have been able to ask questions regarding Reiki and Focusing, its ethical principles and my participation as a client. I have read the above information regarding Reiki and by signing this form, I am agreeing to participate in this approach involving touch and movement.
 I decline the use of Reiki and/or Energy work

____________________________________________________ _________
Client signature Date
Parent or Guardian_________________________________________
Jen Kristel, MA, REAT, RMT APTT
1205 North Avenue
Burlington, Vermont 05408
860-6203
Art Therapy Studio Informed Consent
For Art Therapy, individuals are welcomed into a professional working studio in which there are professional materials used. Included as part of an art therapy session may be, but not limited to is clay; printmaking (including monoprint, and linoleum cut) pastels, recycle sculpture, oils and acrylic paints.
As well, as part of a session may include collecting materials from the woods or nearby beach, to incorporate into an art project.
 At times, individuals work may be present during sessions, while they are drying or setting. As space is limited, confidential storage is not always available. I understand that confidentiality of the client will be a priority.
 I understand that in the art studio there may be sharp tools used for art making. I understand Jennie Kristel will teach me proper use of materials and tools. I agree to be fully responsible for the proper handling of these tools. Jen Kristel is not responsible for any injury that might be incurred during an art session.
 For clients meeting in the studio for Art Therapy, there may be a studio materials fee assessed. This can be worked out with the therapist ahead of time.
 I decline the use of Art Therapy

___________________________________ ________
Signature of Client and/or guardian Date