I understand that as a client of Pursuit of Happiness I may be eligible to receive a range services. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. The goals of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks. I understand that services will be provided by a Licensed Professional Counselor (LPC). Information shared with my LPC is confidential and no information will be released without my consent other than to the Director of Mental Health Services of Pursuit of Happiness. In all other circumstances, consent to release information is given through written authorization signed by me. Verbal consent for limited release of information may be necessary in special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which, according to Texas statutes, include the following: When there is imminent risk of danger to myself or others, clinician is ethically bound to take appropriate necessary steps to prevent such danger. When there is a suspicion that a child, elderly, or someone who cannot otherwise protect themselves from physical or sexual abuse, clinician is legally required to take steps to protect the victim, and to inform the proper authorities. When a valid court order is issued for specific medical records, or if records are subpoened, the clinician and the agency are bound by law to comply with such requests. I understand that while psychotherapy and counseling may provide significant benefits, it may also pose risks. Psychotherapy and counseling may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. Psychotherapy calls for a very active effort on the part of both the clinician and the client in order to be most successful. I understand that I will have to work on things we talk about both during our sessions and at home. I understand that all services are provided by Licensed Professional Counselors (LPC) who practice with a license governed by the Texas State Board of Examiners of Professional Counselors, which is a division of Texas Department of State Health Services. I understand that if I miss two consecutive appointments without notifying my clinician, or if I become non compliant with services as judged by my clinician, Pursuit of Happiness reserves the right to refer my case elsewhere and my case will be closed with Pursuit of Happiness. I understand that in order to reopen my case with Pursuit of Happiness, I must reapply for services. I understand that Pursuit of Happiness operates a limited number of hours per week. If I have an emergency situation, I may leave a message on my clinician’s voicemail to try to schedule an immediate appointment. Unless otherwise discussed with my clinician, on nights and weekends I will contact my family physician or the nearest emergency room and ask for the psychologist/psychiatrist on call. PURSUIT OF HAPPINESS DOES NOT OFFER 24 HOUR CARE. If I have any questions regarding this consent form or about the services offered by Pursuit of Happiness, I may discuss them with my therapist. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by Pursuit of Happiness. I understand that I may stop treatment at any time.
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