Health History Questionnaire
Health History Questionnaire

Please fill out the following health history questionnaire and consent to telehealth services agreement (if applicable) before your first appointment at On Demand Counseling.

Gender Identity *
Has the client has any of the following health problems? *
Allergies/ Drug Sensitivities *
Are you currently pregnant?
Receiving prenatal healthcare?
Are you currently breast feeding?
Any significant pregnancy history?
Have you had any of the following symptoms in the past 60 days? Please check all that apply.
If reporting for a child, has height changed in the past year?
Has your weight changed in the past year?
I consent to telehealth services agreement (if applicable)
Description of Telehealth services:

Telehealth services involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers include both clinical medical On Demand Counseling staff. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

Patient medical records
Live two-way audio and video
Telephone communications

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:
Improved access to medical care by enabling providers and clients to remain in a safe location while receiving necessary services
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.

Possible Risks:
As with any medical procedure, there are potential risks associated with the use of telehealth. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;
How Emergencies are Handled
On Demand Counseling does not provide emergency services. In the event of an emergency, it is imperative that you are aware of resources in your area. As a precaution, we ask that you are aware of two nearby emergency hospitals. In addition, you will need to provide information for an emergency contact person to be maintained in your record.
If you are facing or think you may be facing an emergency situation that could result in harm to yourself or another person, you agree not to seek Telehealth consultation. Instead you agree to seek care immediately through your own local health care provider/practitioner or at the nearest hospital emergency department or by calling 911.

By signing this consent I understand that:
1. I have the option to withhold consent at this time or to withdrawal consent at any time, including any time during a session, without affecting the right to future care, treatment, or risking the loss or withdrawal of services.
2. I will need access to, and familiarity with, the appropriate technology in order to participate in the services provided.
3 The potential benefit of Telehealth services is that I will have greater access to behavioral health clinicians to serve my needs. When appropriate, I will be able to participate in behavioral health services, begin medication, or continue my current medication.
4. The potential risk of Telehealth services is that there could be a partial or complete failure of the equipment being used which could result in the behavioral health clinician's inability to complete the service being provided or prescription process, breaches in confidentiality, and theft of personal information.
5. There is no permanent video or voice recording kept of the Telehealth services provided. Records of Telehealth sessions will be maintained in the same manner of in-person sessions in accordance with On Demand Counseling policies.
6. All existing confidentiality protections apply to Telehealth services.
7. All existing laws regarding client access to information and copies of records apply to Telehealth services.
8. The laws and professional standards that apply to in-person behavioral health services also apply to Telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.
9. Dissemination of client identifiable images or information from the Telehealth interaction to researchers or other entities shall not occur without the consent of the client.
10. If I am not an adult, you need the permission of my parent or legal guardian (and their contact information) for me to participate in Telehealth sessions.
11. I should confirm with my insurance company that Telehealth sessions will be reimbursed. If they are not reimbursed, I am responsible for full payment.
12. As your behavioral health provider, I may determine that due to certain circumstances, Telehealth is no longer appropriate and that we should resume our sessions in-person.

Mahoning County Local Crisis Help:
Help Network of Northeast Ohio: 211 or 330-747-2696
Rape Information & Counseling Program: 330-782-3936
Child Advocacy Center: 330-743-2539
Sojourners House (24 hour assistance for domestic violence victims: 330-747-4040
Family Investigation Unit (Youngstown Police): 330-743-9380
Mahoning County Child Services Board: 330-941-8888
Sexual Assault Nurse Examiner: 330-480-2344
Help Hotline Crisis Center Inc.: 330-747-2696
TDD: 330-744-0579
Mahoning County Prosecutors Office
Victim Witness Division & Juvenile Division

330-740-2082/330-740-2244 ext. 6431

Toll Free Crisis Hotline Numbers:

RAINN (Rape, Abuse & Incest National Network: 1-800-656-4673
VINE (Victim Information & Notification Everyday) 1-800-770-0192
Office of Victim Services; Ohio Department of Rehabilitation & Correction: 1-888-842-8464
Child Abuse: 1-800-422-4453
Child Sexual Abuse: 1-866-367-5444
Family Violence: 1-800-799-7233
Help For Parents: 1-855-427-2736
Human Trafficking: 1-888-373-7888
Mental Illness: 1-800-950-6264
Missing/Abducted Child: 1-800-426-5678
Rape/Incest: 1-800-646-4673
Suicide Prevention: 1-800-273-8255
Substance Abuse: 1-800-784-6776
Youth in Trouble/Runaways: 1-800-786-2929

Local Hospital Emergency Departments:

Mercy Health St. Elizabeth Youngstown- Emergency Department: 330-746-7211
Salem Regional Medical Center- Emergency Department: 330-332-7166

Trumbull County Local Crisis Help:
Help Network of Northeast Ohio: 211 or 330-747-2696
Trumbull Regional Medical Center: 330-841-9011
Mercy Health-St?s. Joseph Warren: 330-841-4000

Columbiana County Local Crisis Help:
Help Network of Northeast Ohio: 211 or 330-424-7767
Salem Regional Medical Center- Emergency Department: 330-332-7166
East Liverpool Community Hospital: 330-385-7200

I consent to Telebehavioral health services in circumstances in which behavioral health clinicians appropriate to meet my needs are not immediately available at the site where I receive services. I also acknowledge that I have had the opportunity to ask questions about the information contained in this document, that I understand the written information provided in this document, and I that may request a copy of this signed agreement.

Consent *