It Takes Courage to Ask for Help....

Kathleen Gleason LPC-S
Boerne Counseling and Consultant Service
110 Hilltop Drive ~ Boerne ~ 78006
 TEL 830. 249. 7432
FAX 830. 755. 6314


Counseling services provided to 
Individuals, Couples, Families, Adolescent, Children and Groups


* Anxiety * Addictions * Relationship * Stress * Grief & Loss *  
* Depression * Communication * Marriage & Family * PTSD
* Trauma-Related Disorders * Child Abuse * Substance Abuse/ Dependency
* Sexual Abuse/ Assault * Family Violence * LGBT * Critical Incident Debriefing

Additional Services

* Substance Abuse Evaluations Conducted ~ Drug & Alcohol Psycho-educational sessions 6 Week Series

 Weekly Support Group for Women of Family Violence

Expert Witness ~ Court Testimony

Speaker/ Presenter - trainings or workshops

Drug and Alcohol Classes ~ 6 week psycho-educational Series
Utilizing a psycho-educational approach, participants gain knowledge about the disease of addiction, cost of addiction and learn coping strategies that encourage recovery. 
A certificate is awarded upon completion to be mailed to court.

Expert Witness ~ Court Testimony

As a Diplomate Clinical Forensic Counselor, Ms. Gleason serves as an expert witness and provides court testimony. 

Theoretical Approaches

Ms. Gleason utilizes several different approaches while conducting psychotherapy depending on the issue(s) presented. 
    Brief Therapy ~ Solution Focused ~ Cognitive Behavioral Therapy
 Rational Emotive Theory ~ Client Centered ~ Psychodynamic

Complete this form after an appointment has been scheduled with therapist.




 PATIENT NAME ___________________________ DATE _____________________, 20____


DATE OF BIRTH ____/____/________ AGE ____ yrs. TEL (____)_____-________  message__


SOCIAL SECURITY NUMBER ______-_____-_______ DL & ST __________________- _______  


HOME ADDRESS ________________________________________ ZIP CODE ____________


EMPLOYER  & ADDRESS ___________________________________ HOW LONG __________


SCHOOL & CITY _____________________________TEL (____) _____-________Grade _____




Name: ____________________ Dose: _________   Name: _________________Dose: ________   

Name: ____________________ Dose: _________   Name: _________________Dose: ________ 

Name: ____________________ Dose: _________   Name: _________________Dose: ________


PRIMARY CARE PHYSICIAN* ______________________________T (____)_____-_________


LIST CHRONIC HEALTH ISSUES_______________________________________________


CURRENT MENTAL HEALTH DIAGNOSES________________________________________


CURRENT STRESSORS ______________________________________________________


GOALS FOR THERAPY _______________________________________________________




 PREVIOUS THERAPY ~ NAME of THERAPIST ____________________________ Helpful  Y  N


WHO MAY WE THANK FOR THE REFERRAL ______________________________________


RESPONSIBLE PARTY (if different from above)


NAME _______________________________ GENDER  M  F RELATIONSHIP ______________


DATE OF BIRTH ___/___/_______ AGE _____  EMPLOYER ____________________________


HOME ADDRESS ______________________________________________________________

                                             Number and Street                                City & State                                        Zip Code


TEL H (____) ______-________ CELL (____) ______-________ TEL W (____) ______-________          


-   -   -   -

IN CASE OF EMERGENCY NOTIFY (if other than above)


NAME _____________________________________ RELATIONSHIP ________________ Gender  M  F


DOB ____/____/_______ TEL (____)_____-________ ADDRESS ______________________________  


PRIMARY INSURANCE  Have you pre-certified any visits?     Y  N  Unsure


Insured’s Name ______________________________ Date of Birth _____/_____/_________ Gender  M  F

Social Security # ______-_____-_______ ID Number _____________________Group Number ___________

Insured’s Employer _________________________ Employer Address _______________________________

Carrier ___________________Tel (_____) ______-_______ Claims Address: _________________________  




Insured’s Name _________________________________ Date of Birth _____/_____/_________ Gender  M  F

Social Security # ______-_____-________ ID Number _____________________Group Number _____________

Insured’s Employer __________________________ Employer Address ________________________________

Carrier ___________________Tel (_____) ______-________ Claims Address: _________________________  




_________ I do not have insurance and will pay in full at the time of service.

_________ I will file my own insurance and will pay in full at the time of service.

_________Please conduct a courtesy billing to my insurance. The reimbursement for services will be directed to me.     


I understand that if problems arise in obtaining payments to practitioner/ therapist from my insurance company, 

I will be responsible to pay the balance of the bill and settle with my insurance carrier unless the practitioner/ therapist 

has otherwise contracted with my insurance company. Furthermore, I agree to pay off any balance on my account 

within 60 days unless I have made other arrangements with practitioner/ therapist. I understand that my account 

may be sent to a collection agency if I do not pay my bill according to this document. If use of a collection agency is 

necessary youwill be charged a 10 % Interest Fee on the balance of my account in addition to a $25 collections fee.         


Responsible Party Signature _____________________________ Date _____________________, 20____                          



I authorize release of information to Kathleen Gleason LPC-S ~ Boerne Counseling and Consultant Service,

and referral sources for the purpose of diagnosis, treatment, consultation, and professional communication.

If I am an insured client, I further authorize the release of information for claims, certification, case management,

quality improvement benefit administration and other purposes related to my health plan. I understand that I this

medical release of information is valid from one year of the signature date.                  


Signature ___________________________ Signed on the _____ day of ___________________, 20 ____

       -   -   -   -



INSURANCE COVERAGE                                                                              □ N/A

You are responsible for obtaining prior authorization for treatment from your insurance carrier. We

Can conduct a courtesy billing upon request. Thus, reimbursement for services will be directed to you. If

your insurance accepts us as an in-network or out-of-network provider you are responsible for

co-payment amounts, deductibles and full payment fees.                                                                Initial here: _____           



 Initial Visit: $150/ 60 minutes

Individual Therapy: $135/ 50 minutes

Two or more Individuals$150/ 50 minutes

Family Therapy: $175/ 60 minutes

Drug and alcohol classes: $225.00-Initial Evaluation; $200.00 per class-8 week series; Certificate

awarded upon completion

Letter or Report Preparation: $250.00

Texts/ Emails: $ 25.00  (per message via text or e-mail; for emergencies only unless authorized by therapist)

Legal Testimony: $1000.00 ½ day, plus per diem, travel and mileage expenses

The retainer of $1000.00 must be paid in cash, one week in advance

Court Accompaniment: $ 300.00 per hour with a minimum of (3) hours. Payment must be made within 

three days-one week of court date


CANCELLATION and MISSED APPOINTMENTS  $135.00                                                     

Scheduled appointment times are reserved especially for you. Evening appointments are in high demand. If an

appointment is missed or canceled with less than 24 hours notice, you will be billed according to the scheduled fee. 

Missed appointments are not covered by your insurance and the charges associated with them are your responsibility. 

Repeated "no-show" appointments or “same day” cancellation could result in referring you to another practitioner. 

Your insurance companycannot be billed. I acknowledge and agree with the above fees.         Initial here: ______                        


$35.00 fee will be assessed in addition to the bank charge, the amount of check and other incurred fees. It is the 

responsibility of the patient to pay this fee. Non-payment of returned checks will result in filing with the Kendall

County Prosecutor's Office.                   Initial here: ______



After-hour calls are to handle emergencies ONLY. A $25.00 fee for every 5-minute telephone

consultation will be charged. Payment is the responsibility of the patient.                                   Initial here: ______


I have read and agree to the Financial Terms and Fees as indicated above.        

                                                                                                                                                                        Initial here______

                                                                                            -   -   -   -

                                                   MENTAL HEALTH DISCLOSURE FORM  


Limits of Confidentiality Statement  In accordance to Texas State Law….


All information between the practitioner/ therapist and the patient is held strictly confidential. There are 

legal exceptions to this:

  • § The patient authorizes a release of information with a signature.
  • § The patient's mental condition becomes an issue in a lawsuit.
  • § The patient presents as a physical danger to self (Johnson v County of Los Angeles, 1983).
  • § The patient presents as a danger to others (Tarasoff v Regents of University of California, 1967).
  • § Child or Elder abuse and/or neglect are suspected (Welfare and Institution and/or Penal Codes).

In the latter two cases, the practitioner is required by law to inform potential victims and legal authorities

so that protective measures can be taken. All written and spoken material from any and all sessions is confidential 

unless written permission is given to release all or part of the information to a specified person, persons, agency. 

or institution. If group therapy is utilized as part of the treatment, details of the group discussion are not to be 

discussed outside of the counseling sessions.                                                                                              Initial here: ______  


Consent for Treatment  


I authorize and request my practitioner, Kathleen Gleason LPC-S ~ Boerne Counseling and Consultant Service, 

to carry out psychotherapy treatment and/or diagnostic procedures, which now, or during 

the course of my treatment become advisable. I understand the purpose of these procedures will be explained to me 

upon my request and that they are subject to my agreement. I also understand that while the course of my 

treatment is designed to be helpful, my practitioner can make no guarantees about the outcome of my treatment. 

Further, the psychotherapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness, 

and anger. I understand that this a normal response to working through unresolved life experiences and that these 

reactions will be worked on between my practitioner and me.  A potential side effect of psychotherapy and/or 

psychological testing is that because of the above feelings that may arise, clients can experience a feeling that 

they are getting worse before beginning to feel they are getting better, and I hereby acknowledge this potential risk.    


 ______________________________________          ___________________________ 20____                 

                 Patient Signature                                                                                                  Date  


Consent for Treatment for Child or Dependent


I am the legal guardian or legal representative of the patient (write child’s or children’s name on the following

space)________________________________________ and on the patient's behalf legally authorize the

practitioner to deliver mental health care services to the patient. All policies described in this statement apply

to the patient that I represent.   


________________________________________          ___________-_______-_____________

                        Print Patient Name                                                                  Patient/ Parent Social Security Number


________________________________________           ___________________________20____            

   Signature of legal guardian/representative                                                                    Date


Relationship to Patient ______________________

-    -   -   -




This consent form is an agreement between you, and Kathleen Gleason LPC-S ~ Boerne Counseling and

Consultant Service. If you are giving your consent on behalf of a child or a dependent, write the first and last name. 

If you are completing this form on yourself, write in your first and last name ___________________________

When we examine, diagnose, treat or refer you we will be collecting what federal law calls Protected Health

Information (PHI), about you. We need to use this information to decide on what treatment is best for you and

 to provide treatment to you. We may also share this information with others who provide treatment to you 

or need it to arrange payment for your treatment or for other business or government functions.  


By signing this form you are agreeing to let us use your information and to send it to others. The Notice Of 

Privacy Practices (HIPPA) explains in more details your rights and how we can use and share your information. 

Please read the laminated forms included in your paperwork before you sign this consent form.


In the future, we may change how we use and share your information and so may change our Notice of Privacy

Practices. If we do change it, you can get a copy by request to our office. If you are concerned about some of your 

information, you have the right to ask us to not use or share some of your information for treatment, payment, or 

administrative purposes. You will have to tell us what you want in writing. Although we will try to respect your

wishes, we are not required to agree to these limitations. However, if we do agree, we promise to comply with

your wishes.  


After you have signed this consent, you have the right to revoke it through written request that you no longer consent. 

We will comply with your wishes about using or sharing information from that time on but we may have already used 

or shared some of your information and cannot change what has already been processed. 


________________________________________            ____________________________, 20___ 

    Print name of patient or legal guardian                                                                             Date

_________________________________________          __________________________________

    Signature of patient or legal guardian                                                                        Relationship to the patient   


Grievance Procedure 


I acknowledge my rights as a client at the Office of Kathleen Gleason LPC-S ~ Boerne Counseling and Consultant 

Service. I understand that in the event that I am dissatisfied with their service as a mental health provider, I may submit 

a grievance to my therapist at any time to register a complaint. If I am dissatisfied with the outcome between myself 

and the provider of services, without resolution of the matter, I may file a formal complaint to:Department of State 

Health Services, Texas State Board of Examiners of Professional Counselors, PO Box , Austin, TX. 787




I, ______________________________________, assume all responsibility for any injuries, losses, or damages.

                  Name of Patient 

Damages that may be incurred while on site at Kathleen Gleason LPC-S, Boerne Counseling and Consultant

Services, located at 110 Hilltop Drive, Boerne, Texas 78006. 


Signature (Patient/Parent) __________________________________ Date ___________________, 20____