Social Work Role Play Session

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Social Science

School

Grand Canyon University

Type

Homework

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qrkqrk07

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SOCIAL WORK ROLE-PLAY SESSION 1

Social work role play session

Student’s name

Institution

Date

SOCIAL WORK ROLE-PLAY SESSION 2

Social work role play session

The volunteer informed consent form for a psychotherapeutic consultation (Individual and

family)

Rob Watson, Ph.D. Clinical Psychologist

I am a licensed clinical psychologist with an American Psychological Association (APA)

certification. Please fill out the following form. Your honesty will enable me to understand your

unique and personal needs.

The information you are providing is private and confidential. National and professional

standards of practice require information on all possible contingencies which may occur in the

course of the session.

Please review to ensure that you have read and understood all things listed here. This consent

form is a contractual force and hence, we cannot proceed until an agreement is reached on all

items listed.

An initial assessment costs $100 per one-hour session. Payments are expected at the end of

sessions. Please feel free to discuss what form of insurance reimbursement you require from me.

Welcome.

Confidential Information Form

First Name: Peter

Middle Name: Craig

Last Name: Boss

Address: 132. West Street. Sumter

Personal Phone Number --------------------------------

Office Phone Number ------------------------------

May I call and leave messages at these phone contacts? Yes____ No_____

Email Address (if applicable): danielyatich65@gmail.com

SOCIAL WORK ROLE-PLAY SESSION 3

Birth date: 12/6/1950

Age: 72

Social Security Number ---------------------------------

Marital Status: Married

Employer ---------------------------

Referee (s) ---------------------------------

His/her Address----------

His/her Phone Number------------

I am allowed to contact the referee (s) above? Yes

Please describe any past counseling or therapy I do not have a history of counseling therapy.

Can you please state how you heard about my services: I was referred to me by my wife who

guided me in the process of booking an appointment.

Are there any issues you want to raise? None at the moment

Note on insurance payments

• Because of challenges and delays in insurance reimbursement, I will ask you to pay at the

start of every session or if you agree, I send a bill which you will pay at the end of the

month.

• A copy of the bill will be submitted with the insurance form and they will cover areas

including Diagnosis and the entire therapy session.

Confidentiality

• Federal and state laws together with professional standards require professional therapists

to maintain high levels of confidentiality except in cases listed below:

1. If there are cases of suspected child mistreatment, elderly abuse, or mistreatment

of a dependent adult.

2. A condition where there is a grave threat to the well-being of the victim.

3. When there is a threat directed to oneself or another person to injure or kill

communicated to the therapist.

4. If the medical insurance company requires the information to be availed to them.

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SOCIAL WORK ROLE-PLAY SESSION 1 Social work role play session Student’s name Institution Date SOCIAL WORK ROLE-PLAY SESSION 2 Social work role play session The volunteer informed consent form for a psychotherapeutic consultation (Individual and family) Rob Watson, Ph.D. Clinical Psychologist I am a licensed clinical psychologist with an American Psychological Association (APA) certification. Please fill out the following form. Your honesty will enable me to understand your unique and personal needs. The information you are providing is private and confidential. National and professional standards of practice require information on all possible contingencies which may occur in the course of the session. Please review to ensure that you have read and understood all things listed here. This consent form is a contractual force and hence, we cannot proceed until an agreement is reached on all items listed. An initial assessment costs $100 per one-hour session. Payments are expected at the end of sessions. Please feel free to discuss what form of insurance reimbursement you require from me. Welcome. Confidential Information Form First Name: Peter Middle Name: Craig Last Name: Boss Address: 132. West Street. Sumter Personal Phone Number -------------------------------Office Phone Number -----------------------------May I call and leave messages at these phone contacts? Yes____ No_____ Email Address (if applicable): danielyatich65@gmail.com SOCIAL WORK ROLE-PLAY SESSION 3 ...
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