2022 Treatment Information and Registration
Alicia Avila Licensed Clinical Social Worker P.C. Ca Lic. LCS19899
3990 Old Town Ave., Suite C203, San Diego, CA 92110 Phn: (858) 344-9440
Alicia@aliciaavila.com                        Fax: (619) 297-3716

Evaluation:  Our first few sessions will involve an evaluation of your needs.  By the end of the evaluation period you will want to make your own assessment about whether you feel comfortable working with me.  It is important that you are working with a therapist that is a good match for you as therapy involves a large commitment of time, money, and energy.  If you are not satisfied with our initial connection I am happy to assist you with other referrals.  

Appointments:  Please come in a few minutes early so that you have an opportunity to focus on what you would like to get out of session.  I begin and end sessions on time and it is to your advantage to come in early so that we do not miss any of our session time.  If you are late, we will still end on time.  
Each session is scheduled for 45 minutes unless you request a longer session at the time of scheduling.  

For confidentiality and to maintain professional boundaries if we see each other outside of session I will not greet you or acknowledge knowing you. This is not meant to be rude and if you initiate a hello I will certainly respond. We will also avoid social media interactions. Let me know if you have questions or want to discuss this further.  

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Email *
Payments:  All services are provided for a fee due at the time of the service.  It is your responsibility to pay at the beginning of each session or 24 hours before your appointment.  My hourly fee is $175 for a 45 minute session and $262 for a 75 minute session. Each appointment time is reserved for you.  If you are late, the session will be shorter and will still need to end the scheduled end  time. If you need to cancel or reschedule with less than 24 hours notice, you will still need to pay for the full session originally scheduled. Please text me with any schedule changes as I do not check email as regularly.  I charge a prorated rate for other professional services you may require such as report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings or consultations with other professionals which you have authorized and requested. I have the right to terminate service to you if fees are not paid in a timely manner.  If your bank uses Zelle you can pay directly from your bank account by using my email address above. The account is “Alicia Avila Licensed Clinical Social”  Please make checks payable to Alicia Avila Licensed Clinical Social Worker P.C. (often this long name will not fit but will work but a portion of it will work as in: Alicia Avila Licensed Clinical S)  If you choose to pay by credit card you will enter your credit card information in response to a text from “Ivy pay” and you will be charged up to 24 hours before each appointment.  Please have your form of payment ready prior to starting the session in order to avoid using session time for payment. *
Required
24 Hour Cancellation Policy:  If you need to cancel or change your appointment time please call or text me at least 24 hours prior to your appointment time to avoid being charged the full session price.  Please do not use email to cancel or request an appointment change as I might not get this in time. *
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Insurance:  I am not “in network” for any insurance and I do not accept insurance nor Medicare.   You have the option of seeing a clinician who takes medicare or your insurance and I will do my best to assist you in that search. If you choose to see me you cannot bill medicare for our visits.  If you have a PPO insurance plan you can choose to submit a bill to them for partial reimbursement for an “out of network” provider if your diagnosis and our work fits the requirements for reimbursement of your insurance.  You may want to contact your PPO to find out if you have a deductible and how much they will reimburse for “out of network outpatient mental health” (a 45 minute session is coded as a “90834” and a 50-80 minute session is an “90837”) Your insurance company can tell you how much they reimburse for each of these services. *
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Contacting Me:  My appointment dates are Tuesdays and Wednesdays and I am often not immediately available by telephone. When I am unavailable, you can leave a voicemail message for me, always including your phone number. If you are difficult to reach, please leave me times when you will be available. If you need to speak to a counselor right away, and I am not available, please call the 24 hour crisis line:  1(888) 724-7240.  If it is an emergency please call 911, go to your closest emergency room, or contact your physician.Please remember that email is not confidential and technical problems can occasionally interfere with my ability to respond. If I have not responded promptly, do not hesitate to contact me again. Unless you specify not to contact you by email (on your registration form) I may occasionally send resource or scheduling information by text or email.  It is not appropriate for us to discuss deep therapy issues over email or text.I can receive or may send you a text regarding schedule changes unless you prefer not to communicate by text as indicated on your registration information.   *
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Confidentiality:  The confidentiality of communication between patient and clinical social worker is protected by law and I can only release information about you and our work to others with your written permission.  However, there are a number of exceptions when a clinical social worker is required by law to disclose confidential information. I am legally required to take action to protect others from harm, even though that requires revealing some information about your treatment.  For example, if I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency.  If I believe that you are threatening serious bodily harm to another, I am required to take protective actions, which may include notifying the potential victim, notifying the police, and seeking appropriate hospitalization.  If you threaten to harm yourself, I may be required to seek hospitalization for you or to contact family members who can help provide protection.  Should any of these situations occur, I will usually discuss this with you before taking any action and you are welcome to ask me about this as needed.  I may occasionally find it helpful to consult about a case with other professionals.  In these consultations, I do not reveal any identifying information of my patient.  The consultant is, of course, also legally bound to keep information confidential.  Unless you object, I will not tell you about these consultations unless I feel it is important to our work together.In most judicial proceedings, you have the right to prevent information about your treatment to be disclosed.  However, in very rare circumstances a judge can sign a court order that may require my testimony if he or she determines that resolution of the issues before him or her demands it.The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of clinical social workers (or marriage and family therapists) You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830. *
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Authorization for Services:  I have read the information in this treatment information and consent and I have asked questions about anything I have not understood.  By signing this form, I freely acknowledge my willingness to participate in psychotherapy to be facilitated by Alicia Outcalt, LCSW.  I understand that I can end treatment at any time and will pay for all services rendered. *
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Name *
Date *
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Date of birth *
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Home address: *
Cell phone # *
Can therapist leave a message at this number? *
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Can therapist text this number? *
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Home phone # *
Can therapist leave a message at this number? *
Required
email address only if it's ok to send messages and links for telehealth appointments using this address *
Emergency contact.  Name, phone number, and relationship *
Primary Care Physician Name and phone number. *
Psychiatrist name and phone number *
Allergies *
Current mediations and what they are for *
Current medical issues *
past medical issues *
General physical health is *
How much caffeine do you consume? *
Personal History.  It can be difficult to get through the initial assessment process but the following information can help us move more quickly into addressing what is most important to you. The more that I know about you and your background the better I can tailor my interventions to you.  I understand that it is difficult to answer these questions openly before we have met.  Please do not feel obligated to answer anything that you are not ready to share with me at this time or in this written format.  You can simply leave certain areas blank and make comments on areas that you feel comfortable with.  Feel free to add any other information I have not asked but that you want to make sure that I know right away.
Who referred you for this treatment or how did you hear about this therapist? *
What made you decide to come in for treatment and why now? *
How would you know that treatment was successful? *
Any concurrent treatment you are engaged in? *
Past therapy experiences, when, length of treatment, where, what was helpful, what was not helpful? *
Past drug or alcohol treatment experiences.  When, length of treatment, Where, what was helpful, what was not helpful? *
Inpatient or residential treatment?  When, length of treatment, where, what was helpful, what was not helpful? *
Where did you grow up? (list as many places with ages or dates as appropriate and who you lived with you) *
Please list your siblings, their ages and what part of the country they live in now. *
Family members with emotional issues or alcohol and drug related issues, suicide attempts, or other concerns? *
How did you do in school both academically and socially? *
Highest Grade/Degree Earned (include date and area of study if applicable) *
Current Occupation/Employer and Length of time with this employer? *
Longest time with one employer/job? *
Significant past events *
How much alcohol do you consume per day? And how many days per week? *
What other drugs do you use and for how long have you been using each? *
Describe benefits of alcohol and / or each drug you use regularly or on occasion. *
Problems experienced related to alcohol use or drug use? *
When do you feel you have been at your best? What has been the best time of your life so far? *
Accomplishments *
Hobbies?  What do you do for fun? *
What would you like to be doing for fun? *
Who do you count on for support? *
Who lives with you at this time? *
Ace Questionnaire:  In your first 18 years of life...
Our relationships and experiences—even those in childhood—can affect our health and well-being. Difficult
childhood experiences are very common. Please tell us whether you have had any of the experiences listed
below, as they may be affecting your health today or may affect your health in the future. This information will
help you and your provider better understand how to work together to support your health and well-being.
1. Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you? *
2. Did you lose a parent through divorce, abandonment, death, or other reason? *
3. Did you live with anyone who was depressed, mentally ill, or attempted suicide? *
4. Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs? *
5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other? *
6. Did you live with anyone who went to jail or prison? *
7. Did a parent or adult in your home ever swear at you, insult you, or put you down? *
8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? *
9. Did you feel that no one in your family loved you or thought you were special? *
10. Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginalintercourse/penetration)? *
Do you believe these experiences have affected your health? *
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