CLIENT INFORMATION AND COUNSELOR PROFESSIONAL DISCLOSURE

Melanie Bikis, Licensed Mental Health Counselor Associate

The following information is designed to inform you about my background and ensure that you understand the nature of our professional therapeutic relationship and your rights as a client.

I am a Licensed Mental Health Associate registered in the state of Washington. As an associate, I am currently under the supervision of Carly Henderson at MindWise Therapy LLC. If you have any concerns or questions, please feel free to reach out to Carly Henderson.

Professional Services

I provide an eclectic approach to counseling, drawing from existential psychotherapy as my primary lens. However, I utilize various tools in my individual counseling sessions for children. Existential psychotherapy is well suited for working with children as it focuses on their choices and meaning-making systems. I have received training to address the following presenting issues: social and relational conflicts, grief, depression, anxiety, neurodivergence (ADHD, autism, sensory issues, etc.), disabilities, LGBTQAI+ issues, and the impacts of sexism and racism on children. My therapeutic approach incorporates several major theories of counseling, including Solution-Focused, Cognitive-Behavioral, Gestalt, Existential, Person-Centered, and expressive art therapy, among others. I tailor my approach to meet the specific needs of each client.

I firmly believe that every child possesses the strength and potential to navigate life's challenges, and that most issues are developmentally based. Children are doing the best they can with the knowledge they have. My goal is to help my clients discover their own potential through unconditional positive regard, and to equip them with skills and strategies that will empower them to achieve their goals. I strive to create the right conditions for personal growth.

The counseling process involves a collaborative relationship between the client, guardians, and myself, within an open environment where clients are encouraged to share their thoughts and feelings honestly. I often work openly with families, children, and even school personnel to provide the best possible support for the client. Your active participation and personal work outside of sessions are essential for counseling to be effective. At times, I may suggest various activities outside of the counseling hour to help you make progress towards your goals.

I am deeply committed to promoting cultural sensitivity and embracing diversity within my counseling practice. I value the unique backgrounds, experiences, and perspectives of each individual and strive to create a safe and inclusive space for clients from all cultural, ethnic, religious, and social backgrounds. I continuously expand my knowledge and understanding of various cultural identities, beliefs, and practices to provide culturally competent care. By recognizing the influence of culture on individual experiences, I tailor my therapeutic approach to align with the unique needs and values of each client. I actively address the impacts of sexism, racism, and discrimination, and aim to create an environment where all clients feel validated, heard, and understood. I am dedicated to ongoing education and self-reflection to deepen my cultural competence and ensure an inclusive practice. Open dialogue about cultural differences is welcomed, as I strive to provide a therapeutic experience that is respectful, inclusive, and responsive to the diverse identities and backgrounds of each client.

Confidentiality

I value your right to privacy, and any information shared in our sessions will remain confidential. However, there are three exceptions to confidentiality. I am ethically obligated to break confidentiality if I believe you are in imminent danger of harming yourself or others, if you report abuse or neglect of a third party who is a child, older adult, or disabled individual, or if I come under court order to release information.

To protect the privacy and confidentiality of my clients, it is my professional practice not to initiate greetings or acknowledge clients in public places unless they indicate a desire for recognition. This ensures that clients have control over the disclosure of their therapeutic relationship and maintains their confidentiality outside of our counseling sessions.

In accordance with professional ethics, I may consult with my direct supervisors, other counselors, and peers in my supervision group from time to time regarding certain cases. I will strive to reveal as little as possible about clients' identities during these consultations.

Both my supervisor and any consultees are mental health professionals who are held to the same standards of confidentiality as I am. These consultations are intended to help me provide the best services possible. Except for the three exceptions to confidentiality and consultations, I require specific signed permission from you to disclose any aspects of our counseling relationship to an outside party.

Access to Records: As allowed by law, clients have access to their own records or the records of their minor child(ren). This service is provided free of charge by this practice.

Court-related Issues: I do not provide expert witness or testimonial services. If you, your attorney, or your spouse/ex-spouse's attorney subpoena me, a $1000 retainer fee will be required upfront. Additionally, you will be billed $300 per hour, which includes but is not limited to court time, travel time, review of materials, and report preparation. The parent initiating the action will be responsible for payment. By initialing, you agree to this payment.

Length of Sessions, Fees, and Cancellations

Therapy sessions typically last 50 minutes. While I offer a complimentary 20-minute consultation for new families, my regular hourly fee is $140. I also provide the flexibility of drop-in and emergency client hours for when families may need extra support, such as guidance around school issues or new conflicts at home. These hours are available on a first-come, first-served basis and are subject to the same hourly fee. All contact with clients or their respective families incurs a fee prorated in 15-minute increments. I have a limited number of reduced sliding scale slots available for families in need. If you need to cancel or reschedule an appointment, please notify me at least 24 hours before your scheduled appointment time by calling 913-244-7885. No-shows or late cancellations will be charged a flat rate of 45.00/hr.

Boundaries/Limitations

1. Communication Outside of Sessions: While I strive to provide support and guidance during scheduled sessions, I do not provide 24/7 on-call services. As such, I may not be available for immediate response to phone calls, emails, or text messages outside of our scheduled appointments. If you require immediate assistance or are facing an emergency, please contact the appropriate emergency services or helpline.
2. Availability During Emergencies: In the event of a crisis or emergency situation, it is important to reach out to the appropriate emergency services or helpline. While I will make every effort to respond to urgent matters, please understand that there may be instances where I am unavailable due to prior commitments or personal circumstances.
3. Limits of Confidentiality in Electronic Communication and Social Media: It is important to recognize that communication via electronic means, including email, text messages, and social media platforms, may not always be fully secure or confidential. While I take precautions to ensure the privacy of our electronic communications, I cannot guarantee absolute confidentiality. Therefore, I encourage you to use discretion and avoid sharing sensitive or confidential information through electronic channels.
4. Dual Relationships: To maintain the integrity of the therapeutic relationship, it is essential to establish clear boundaries. I will not engage in any form of social, personal, or business relationships with clients during the course of our counseling relationship. This includes interactions on social media platforms.

By participating in counseling sessions with me, you acknowledge and agree to respect these boundaries and limitations to ensure the effectiveness and professionalism of our therapeutic relationship.

Please let me know if you have any questions or concerns regarding these boundaries and limitations. Your understanding and cooperation are greatly appreciated.

Complaint Procedures

If you are not satisfied with any aspect of your counseling experience, please discuss it with me immediately. If you believe you have been treated unethically and are unable to resolve the issue with me, you may contact my site supervisor, for clarification of client rights or to file a complaint. You may also register any complaints with the National Board of Certified Counselors at 3 Terrace Way, Greensboro, NC 27403.

If you have any questions or concerns about the information provided above, please feel free to discuss them with me. To indicate that you have read and understood this information, and agree to the terms outlined in this professional disclosure statement, please sign and date the form below. A copy of the signed form will be returned to you, and one will be kept by this site in your confidential records.

_______________________________​ _________________________________

Name Client's Signature

 ___________ Date

CHILD THERAPY SERVICES CONTRACT

Therapist: Melanie Bikis

Client: _________

This contract outlines the terms and conditions for child therapy services provided by Melanie Bikis. By signing below, the parent(s) or legal guardian(s) agree to the following:

1. Emergency Contact Information:

• Parent(s) or legal guardian(s) will provide accurate and up-to-date emergency contact information.
• This includes the names, phone numbers, and relationships of individuals who can be reached in case of an emergency involving the child during therapy sessions.

2. Authorization for Emergency Medical Care:

• Parent(s) or legal guardian(s) grant permission for [Therapist's Name] and/or designated staff to seek emergency medical care for the child if necessary during therapy sessions.
• This authorization includes consent for medical treatment deemed necessary by medical professionals.

3. Confidentiality and Privacy:

• Melanie Bikis will maintain the confidentiality and privacy of all information shared during therapy sessions, as outlined in the confidentiality agreement provided separately.
• Parent(s) or legal guardian(s) agree to respect the confidentiality of other clients and families they may encounter during their child's therapy sessions.

4. Termination of Services:

• Either party may terminate therapy services with written notice provided in advance, except in situations where immediate termination is necessary due to safety concerns or ethical considerations.

I, [Parent/Guardian's Name] _________________________________, have read and understood the terms and conditions outlined in this contract. I agree to comply with the policy, provide accurate emergency contact information, and grant authorization for emergency medical care as stated above.

Parent/Guardian's Signature: _______________________________

Date: ______________________

Therapist's Signature: _____________________________________

Date: _____________________

EMERGENCY CONTACT FORM

Child's Name: ________________________

Date of Birth: ________________________

Therapist's Name: ________________________

Emergency Contact Information:

1. Parent/Guardian:

• Name: ________________________
• Relationship to Child: ________________________
• Phone Number: ________________________
• Alternate Phone Number: ________________________

2. Emergency Contact 1:

• Name: ________________________
• Relationship to Child: ________________________
• Phone Number: ________________________
• Alternate Phone Number: ________________________

3. Emergency Contact 2:

• Name: ________________________
• Relationship to Child: ________________________
• Phone Number: ________________________
• Alternate Phone Number: ________________________

Medical Information:

Child's Primary Physician: ________________________

Phone Number: ________________________

Insurance Information (if applicable): Insurance Provider: ________________________

Policy Number: ________________________

Group Number: ________________________

Additional Notes or Special Instructions: ________________________

I, [Parent/Guardian's Name], confirm that the above information is accurate and up-to-date. I understand the importance of providing emergency contact information and authorize Melanie Bikis to seek emergency medical care for my child if necessary during therapy sessions.

Parent/Guardian's Signature + Date: ______________________________