We are now SouthWest Counseling (SWC), an informal affiliation of former Southwest Counseling Associates staff members, now in private practice. As the result of an executive board decision, Southwest Counseling Associates (SCA) dissolved on November 30, 2021. To preserve the mission, standards and culture of SCA, therapists listed on this site continue to work together in supporting each other and serving our community. DETAILS
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Client Documents
Links on this page allow you to access necessary forms without coming to the office. You can view, print and fill out these documents in PDF format, displayed in a PDF reader installed on your computer. Click here to download a free PDF reader if your computer does not have one. You can also view, fill out and sign these documents online. Look for the “Online” link for each document.
Intake Documents
First-time clients and those returning after an absence of six months or more must fill out and sign a set of intake documents before treatment can begin. You can come 15 minutes before your appointment and fill them out in the office; you can print and fill out a PDF file in advance, or you can complete the papers online.
Intake documents are personalized to each therapist. Click on “Personalized Intake Papers” below, then find your therapist’s name. Choose “View/Print” to access a PDF file that you can physically sign; choose “Online” to fill out and sign an electronic version of the papers and send it in encrypted form directly to SCA. NOTE: Fill out these documents ONLY AFTER you have set an appointment with your therapist.
Personalized Intake Documents
Dr Dan Rumberger: View/Print | Online
Elizabeth Dodrill: View/Print | Online
Hannah Reutter: View/Print | Online
Jennifer Pollock: View/Print | Online
Jim Lewis: View/Print | Online
Julia Al-Sager: View/Print | Online
Larry Zirschky: View/Print | Online
Dr Monte Hasz: View/Print | Online
Paula Nolls: View/Print | Online
Todd Challis: View/Print | Online
Disclosure and Consent Document
New clients do not use this form. Please go to the previous section and fill out your therapist’s Intake Documents.
The Disclosure and Consent document informs clients of their rights, their therapist’s qualifications, and SCA’s policies. Choose your therapist’s Disclosure and Consent form below ONLY if you are an existing client and your therapist needs you to update your signature or sign a current version of the document.
Disclosure and Consent documents are personalized to each therapist. Find your therapist’s name in the drop-down list below and click one of the links next to it for your choice of format. Click “View/Print” to physically sign a PDF version of the file; click “Online” to fill out and sign an electronic version and send it in encrypted form directly to SCA.
Disclosure and Consent
Allison Motsenbocker: View/Print | Online
Dr Dan Rumberger: View/Print | Online
Deanna McGrath: View/Print | Online
Elizabeth Dodrill:View/Print | Online
Hannah Reutter: View/Print | Online
Jennifer Pollock: View/Print | Online
Jim Lewis: View/Print | Online
Julia Al-Sager: View/Print | Online
Kaitlin Swenson: View/Print | Online
Kerri Frantz: View/Print | Online
Larry Zirschky: View/Print | Online
Leanne DeRemer: View/Print | Online
Lisa Laws: View/Print | Online
Dr Monte Hasz: View/Print | Online
Paula Nolls: View/Print | Online
Todd Challis: View/Print | Online
Teletherapy Disclosure and Consent
Therapy by phone or video has become an important part of SCA’s services during the health crisis. Our teletherapy forms describe the process, standards and limitations of teletherapy. You will need to sign the Teletherapy Disclosure and Consent document before you begin remote therapy. Use the following links to create and sign a hard copy of the forms, or access the online form.
Internship Site Informed Consent
This form asks whether you want to allow an intern therapist to participate in some sessions with your therapist as part of SCA’s training program. You are free to say ‘yes’ or ‘no’
Acknowledgement and Consent for EMDR Therapy
Whether you are a new or existing client, you must read and sign this document before starting Eye Movement and Desensitization Reprocessing therapy (EMDR). The document explains the process, lists steps for preparation and describes what you may experience.
Release of Information Form
This optional form grants your therapist permission to communicate with a third party for your benefit. You must complete this form before your therapist can communicate with the third party.
Insurance Information
SCA must have current insurance information on each of our clients, whether or not the client’s insurance is covering counseling fees. If you are an established client and your insurance has changed, it is important that you fill out a new Insurance Information form so we can update our records. Click the links below to create and fill out a hard copy, or to complete the form online.
Memo of Understanding
At times a client may wish to invite a trusted family member or friend to sit in on one or more treatment sessions as a support to the client. This document explains to the supporting person the specific conditions for that to happen. The visiting person must sign this document before the first visit, after which as many as two more visits are permissible. Click the links below to choose a printable PDF file or an online form to sign.
Notice of Privacy Practices
In keeping with federal law, we provide all our clients with a detailed statement explaining our policies and procedures to safeguard your private information. Click below to access our Notice of Privacy Practices.
Credit Card Information
Please fill out this form completely to facilitate credit card payment for your treatment.
Preauthorization
FOR THERAPISTS ONLY. Please fill in the same information on this form that you would normally provide on a paper preauth, then click “submit.”