Forms - reStory Counseling

New Patient Intake Forms

Prior to your session, please be sure to fill out the New Patient Intake forms. You can either download and complete the forms or you can fill out the fields below and submit them online.
To download and print forms click below:

Zoom Intake Forms Download

In Person Intake Forms Download

Online Form Submission

To submit your New Patient Intake forms online, please fill out the fields below:

Name:(required)

Date of Birth:(required)

Current Age:(required)

Address (Street, City, State & Zipcode):(required)

Email:(required)

Phone Number:(required)

Sharing information about yourself will better help me to get to know you and know how to plan for our time together. Please answer the following questions before your first appointment.

1. What are the main concerns you have for seeking help at this time? Please include your symptoms, pain, illness, injuries, onset, upsets, losses, functional problems, fears, worries, etc.:

2. What would you like to achieve from counseling (what are your goals)?

3. List the medications, supplements, remedies and any herbs you are currently taking:

If other, please list here:

5. Do you have a church home?

Yes No

If so, what is it?

6. Do you smoke?

Yes No

If yes, please check all that apply:

Cigar Cigarette Pipe

How many do you smoke per day?

Did you ever consume some tobacco?

Yes No

When did you quit?

How much did you smoke?

7. How much alcohol do you drink, if any? Please list all that apply: • None • Number of beers/day • Number of glasses of wine/day • Number of drinks/day

8. Do you use recreational drugs?

Yes No

If yes, what do you use and how often?

9. Have you ever had a problem with eating or an eating disorder?

Yes No

Check all that apply:

Anorexia Bulimia Binging Overeating

10. How is your sleep?

11. What are the stressors in your life right now?

12. How do you reduce your stress?

13. Have you experienced any anxiety or depression lately?

Anxiety Depression Mixed

Please describe:

14. Have you recently or in the past thought about suicide?

Yes No

If yes, when?

Have you ever attempted suicide?

Yes No

If your answer is yes to either of these questions, please describe what treatment you’ve had:

15. Have you ever been or are you presently in counseling or psychotherapy?

Yes No Other Therapeutic Work

Describe why you went and your experience:

16. What is your occupation?

Do you enjoy your work:

Yes No

Describe why or why not:

18. Gender Identity:

19. What kind of support system do you have?

Family Friends Relative Other

If other, please list:

Spouse/Partner's name:

If divorced, when did you get divorced?

How was the process?

If remarried, when did you get remarried?

Do you have a blended family?

Yes No

How many children? (Please include number of yours, spouse's, and total together)

26. Your Children: (Please list Names, ages, and where they are living)

27. Family History Please list name, age, age at death and if there were any illnesses for the following: • Mother • Step Mother • Father • Step Father • Sisters • Brothers

28. Briefly describe your childhood, particularly in relationship to your family of origin:

29. Briefly describe your present living situation:

30. What is your level of education?

31. What do you enjoy doing in your life?

32. Is there anything else you would like me to know right now about you?

Client Commitment Informed Consent

It is an honor to commence work in your story with you. This informed consent is designed to give you information about my practice and our professional relationship. reStory Counseling helps clients connect to their bodies, souls, and minds in order to gain access to a greater sense of love and safety in their daily lives.

I will work with you to help you care for moments in your story that feel fractured or confusing by bridging current therapeutic techniques with a sensitivity to the biblical narrative. I see the goal of our time as equipping you with tools for managing your stresses and triggers.

CONFIDENTIALITY
I maintain the confidentiality and privacy of each client and their records as protected by state law and professional ethics. There are a few, rare instances where safety takes precedence over confidentiality. These situations include: (1) if I suspect you intend to harm yourself, another person, or property; (2) when I suspect a child, elder or dependent adult has been or will be abused or neglected. (3) In rare circumstances, counselors can be ordered by a judge to release information (subpoena). In all other circumstances, I maintain confidentiality unless you give me expressed written authorization to do otherwise.

Please note: Once information leaves my office I have no control over what happens with it. I do consult regularly with other professionals regarding clients with whom I work; however, a client’s identity remains completely anonymous and I fully maintain confidentiality.

SCOPE OF PRACTICE AND PROCESS OF THERAPY
I am a Board-Certified Biblical Counselor certified by the International Board of Professional and Pastoral Counselors. I also have a Master’s Diploma in Biblical Counseling for Marriage and Family.

Biblically-based
The foundation of my work is directed by God’s Word and biblical truth. I utilize biblical truth and narrative to inform my own and others’ stories, and I believe God’s larger story of redemption and restoration is always at work. As a member of a local church, the values for my practice align with those found in the gospel, and I never facilitate a session that disconnects a client from these core messages: love, grace, embodiment, and empowerment.

Somatic Approach
I take a body-oriented/neurobiological approach to healing trauma in our sessions. I am a Somatic Experiencing Practitioner certified through the Somatic Experiencing Institute. Additionally, I have a B.S. from Texas A&M University.

Expertise
My focus is on wellness and my expertise includes anxiety, depression, stress-related problems, Developmental Trauma, Complex Trauma, Sexual trauma, PTSD, abortion wounds, relationship problems, and life transitions. During our time, I emphasize proper understanding of boundaries, development of self-regulation skills and resiliency. If I feel that I cannot help you, I will provide referrals when possible. While it is impossible to predict the exact outcomes of therapy, we will work together toward the goals we establish. In addition to the work in my office, I may suggest some work for you to do between sessions. It is not uncommon for clients to feel levels of sadness, anxiety, fear as well as joy, happiness, and love throughout the counseling therapy. Your feedback is very important.

FEES & INSURANCE
Please contact DeeDe for the 50-minute session fee. The frequency of treatment will depend upon your needs, scheduling, and the severity of your troubles. I do not participate with insurance companies.

PAYMENT
Payment is due at the beginning of each session by cash, check, Venmo, PayPal or Square Cash. Please make checks out to reStory Counseling, LLC. There is a $25 charge for returned checks.

MISSED APPOINTMENT/NO SHOW/LATE CANCELLATION
I charge in full for missed appointments and appointments not canceled within 24 hours of the scheduled time. If you cancel because of inclement weather I can try to schedule a videoconference with you instead of the in-office appointment.

EMAIL/TEXTING
I cannot guarantee the confidentiality of any electronic media used to contact me. I will only use text and email to schedule appointments, answer very short questions or make referrals and suggestions for books. It will not replace or substitute for therapy and cannot be considered therapy. It may take me a couple of days to reply to a text or email.

EMERGENCIES AND VACATION
Upon occasion, an emergency situation arises. In case of an emergency, you should call 911 or go to the nearest emergency room after leaving a message. I will call you back as soon as possible. When I am on vacation I may not be available.

ETHICS
I abide by the Code of Ethics of the International Board of Professional and Pastoral Counselors. My intent is to help you. Please ask me any questions you have as you move through the healing journey.

The road to healing starts with our stories. Again, thank you for the privilege of sharing yours with me.

Sincerely,
DeeDe Bormann, BCBC, SEP, TTP

Client Commitment Informed Consent: I have read the informed consent and have been given an opportunity to have my questions answered. Please write your full name if you agree to these terms.(required)

Please select if you are signing as client or parent/guardian:

Client Parent or Guardian

Somatic Experiencing Informed Consent

When appropriate, and according to my clinical judgment, I will use Somatic Experiencing (SE) in our work together. SE is a naturalistic approach to the resolution and healing of trauma developed by Dr. Peter Levine and is supported by research.

SE employs awareness of body sensation to help people “renegotiate” and heal rather than re-live or re-enact trauma.
SE’s guidance of the bodily “felt sense,” allows the highly aroused survival energies to be safely experienced and gradually discharged.
SE may employ touch in support of the renegotiation process.
SE “titrates” experience (breaks down into small, incremental steps), rather than evoking catharsis – which can overwhelm the regulatory mechanisms of the organism.

For more information about SE please note the following references:

Levine, P. and Frederick, A. (1997). Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences. Berkeley, CA: North Atlantic Books.
Kline, M. and Levine, P. (2007). Trauma Through a Child’s Eyes: Awakening the Ordinary Miracle of Healing. Berkeley, CA: North Atlantic Books.
Levine, P. (2010). In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. North Atlantic Press.

For further references and information online about SE go to http://www.traumahealing.com.

SE can result in a number of benefits to you, such as relief of traumatic stress symptoms, increased resiliency, and resourcefulness. Like any other treatment, it may also have unintended negative “side effects.” It is important that you are aware that there are other forms of body-oriented and somatic psychotherapy. The United States Association of Body Psychotherapy (www.usabp.org) is a good source of information about other modalities.

Obviously, there are also many non-somatic focused forms of psychotherapy and counseling that you can choose from. As with all therapy, it is your responsibility to tell me when you are uncomfortable with any parts of the treatment. If you have any questions about SE or other treatments, please ask and I will do my best to answer your questions in full. You have the right to refuse or terminate treatment at all times, or to refuse techniques or interventions I may propose or employ.

I have read the above informed consent, understand, and agree to it.

Somatic Experiencing Informed Consent: Please print your full name if you agree to these terms.(required)

Telepsychology Informed Consent

This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between us.

Benefits and Risks of Telepsychology
Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location.
This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telepsychology, however, requires technical competence on both our parts to be helpful. Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example:

Risks to confidentiality. Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end, I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
Issues related to technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
Crisis management and intervention. Usually, I will not engage in telepsychology with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telepsychology, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telepsychology work.
Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is a debate about a therapist’s ability to fully understand nonverbal information when working remotely.

Electronic Communications
We will decide together which kind of telepsychology service to use. You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology.

For communication between sessions, I only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will not discuss any clinical information by email or text and prefer that you do not either. Also, I do not regularly check my email or texts, nor do I respond immediately, so these methods should not be used if there is an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact in my absence if necessary.

Confidentiality
I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).

The extent of confidentiality and the exceptions to confidentiality that I outlined in my Informed Consent still apply in telepsychology. Please let me know if you have any questions about exceptions to confidentiality.

Appropriateness of Telepsychology
From time to time, we may schedule in-person sessions to “check-in” with one another. I will let you know if I decide that telepsychology is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology
Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telepsychology services. I will ask you to identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.

If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, [include any local hotlines or other resources], or go to your nearest emergency room. Call me back after you have called or obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the telepsychology platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me on the phone number I provided you (913-244-3770).

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Fees
The same fee rates will apply for telepsychology as apply for in-person psychotherapy.

Records
The telepsychology sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session, in the same way, I maintain records of in-person sessions in accordance with my policies.

Informed Consent
This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions.

Telepsychology Informed Consent: Please print your full name if you agree to these terms.

Touch Therapy Informed Consent

When appropriate, and according to my clinical judgment, with your approval, I will use touch in our work together. I draw from my experience in Somatic Experiencing, Trauma-Sensitive Touch Training and my understanding of Somatic Psychology.

Trauma-Sensitive Touch is a method of realigning the major segment of the body through the manipulation of the fascial connective tissues which is effective in loosening the body’s armor, freeing the body from chronic defensive postures that were likely adopted in childhood to protect the child from a perceived dangerous environment. It can also fight the effects of aging and illness which may result in shortening and thickening of the connective tissues, causing the individual to feel tight and “stuck” in their body. This “stuck” quality has its synchronous correlate of feeling stuck in the psychological processes.

Somatic psychology postulates that the body and mind are one and can’t be artificially separated. Much of our learning as humans has been nonverbal through the body. Much of how we feel about ourselves comes from these non-verbal touch experiences. Feelings of being lovable and nurtured are communicated to the infant through touch. When loving touch doesn’t happen in infancy and childhood new patterns of being nurtured and deserving can be learned through the appropriate use of touch during a state of mindfulness during the therapy session.

Touch can help clients establish more appropriate and healthier boundaries in their life as it helps a nervous system understand where they begin and end. Some clients use the holding of breath to modulate and regulate the intensity of their feelings. Traumatic and frightening situations can cause a freeze response in the body which mutes feelings and experience. With touch, clients may restore their breath and reconnect with feelings, spontaneity, and aliveness.

I consent to the use of touch in therapy and will make any concerns and considerations known to my therapist as they arise.

Touch Therapy Informed Consent: Please print your full name if you agree to these terms.