Consent Form


VINTAGE HEALTH WELLNESS CENTRE
We are a registered Psychotherapy center with vast years of experience specializing in various therapy techniques. We value our relationship with our clients and believe that such a relationship is the beacon in the healing process. We believe each individual is unique and has their way of addressing resolutions. Thus, our wellness model is client-centered and holistic to facilitate supporting our clients to empower themselves by focusing on what works best for them and not on a systematic approach. We are rooted in the belief that every individual has the solutions to their challenges, and our role is to provide a nurturing environment to aid thought processing and decision-making through thought untangling.

Unlocking Your Wellbeing, Once Conversation at a Time!!

CLIENT'S RIGHTS
1. . Unless there is an emergency, all the therapy sessions are private and confidential except for specific exceptions described below:
a. Child, elder, or dependent abuse

b. Expressed threats of violence toward an ascertainable victim,

c. Detailed planning or concrete signs of future suicide attempts,

d. Sharing information is necessary to facilitate client care across multiple providers,

e. Sharing information is necessary for the treatment,

f. Requests from legal and administrative institutions.
2. With the Client's prior written consent, the Psychotherapist may legally speak to another healthcare provider or the Client's family in emergencies. The Client may direct the therapist to share information with whomever the Client desires, and the Client may change their mind anytime and revoke the permission.
3. The therapist is allowed to keep brief notes of the therapy session, which shall be kept in strict confidence.
4. The Client may ask what to expect during and after the therapy.
5. The Client may decline to proceed with the therapy regarding the therapist's techniques.
6. The Client may cease to continue therapy anytime, without any impediment, and may return to therapy anytime.
7. The therapist has the right to dismiss the Client from therapy.

AKNOWLEDGEMENT
I have reviewed this professional Psychotherapy Informed Consent and Confidentiality Agreement. I understand the fees and cancellation policy, accept this agreement, and consent to Psychotherapy with Vintage Health Wellness Center.
PHQ-9 and GAD-7 Mental Health Screening Form

Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by: Not at all Several days More than half the days Nearly every day
1. Little interest or pleasure in doing things

General Anxiety Disorder (GAD-7)

Over the last 2 weeks, how often have you been bothered by: Not at all Several days More than half the days Nearly every day
1. Feeling nervous, anxious, or on edge

Impact of Symptoms

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues,
with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute, 1999.

Stress & Coping Self-Test

Stress & Coping Self-Test

Instructions

Answer all 18 of the following questions about how you feel and how things have been going with you during the past month. Mark the response that best applies to you.

Question A B C D E F
How have you been feeling in general? In an excellent frame of mind In a very good mood In a good mood mostly My mood has been up and down In a poor frame of mind mostly In a very poor frame of mind

Additional Ratings

How concerned or worried have you been about your health? Not concerned at all Very concerned

Scoring

Your score for each question is the number beside each check box. Add the scores for all questions to get a total score.