Informed Consent
Informed Consent for Abbie, MSW

Thank you for choosing to work with Abbie Gonzales MSW LMSW and Better with Abbie. Abbie has
been a licensed Master's Degree Social Worker for 17 years. She  graduated from Hope College in 2003 and The University of Michigan School of Social Work in 2004. She has since worked with a number of
different populations including adolescents, chronic illness, cancer, depression, anxiety and grief. Her Michigan License ID is: 6801091805. Sessions are generally 45-55 mins. This document is intended to inform
you of our policies, state and federal laws and your client rights. Please let her know if you have any questions.

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Full Name: *
Phone number: *
Email: *
Physical Address: *
Emergency Contact: *
Preferred Hospital in the event of an Emergency: *
I understand that my therapist holds all sessions engaging in Telehealth services to provide me with treatment. I understand that this is a necessity and an abundance of caution that has originate due to the Coronavirus Pandemic. This will continue until such a time that my therapist and I are able/agree to meet in person. (Please enter initials) *
 LOCATION: I understand that it is my obligation to notify my therapist of any persons in the location, either on or off camera and who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my therapist at the onset of each session that I am aware that confidential information may be  discussed.(Please enter initials) *
EMERGENCY SITUATIONS: You are aware of the fact that the Online Counseling Services are not a complete substitute for a face-to-face examination and/or session by a licensed qualified professional. The on-line venue does not allow for emergency response, therefore if you have a crisis/emergency please call 911 or go to the nearest hospital. If you are thinking about suicide or if you are considering taking actions that may cause harm to you or to others or if you feel that you or any other person may be in any danger or if you have any medical emergency, you must immediately call the emergency service number 911 or the National Suicide Hotline Toll-FreeNumber at 1-800-273-TALK (8255) or other local suicide hotlines. You acknowledge, confirm and agree that the online platform used to communicate with Ms. Gonzales is not designed for use in any of the aforementioned cases and that you must not use the platform in any of the aforementioned cases. The listed Emergency Contact person will be used in case you are unable to be reached  and/or need to be reached in an emergency. Your emergency contact information will only be used to contact you for emergency and safety reasons.(Please enter initials) *
NOTICE OF CONFIDENTIALITY AND PRIVACY RIGHTS: Your ProtectedHealth Information (PHI) is protected by state and federal law(HIPAA). This information can only be disclosed with your express permission or as required or permitted by law. All of our written communication is available to you on your personal electronic device to keep or share at your discretion. It is recommended that you keep this information/communication private and password protected if you copy or store it on your personal electronic device(s).In general, I may not disclose any personal information without your permission andI must protect and keep your information private. Any electronic device I use to access PHI is password protected to prevent unauthorized access. There are certain conditions in which I may be permitted or required to disclose certain information without your express consent. They are as follows: For Treatment Purposes: At times I may discuss a case with a professional colleague. In these instances will omit or change any identifying information. This disclosure is purely to enhance my skill and treatment in a specific situation and is used judiciously. Any colleague is also bound by HIPAA laws.Without Authorization: The following are disclosures that may be required by law in certain circumstances. · Abuse and Neglect: As a mandated reporter, I am required to report suspected abuse or neglect of a child (under 18), disabled person, or elder (65 or older).Judicial and Administrative Proceedings: Disclosure pursuant to a valid subpoena. · National Security: Disclosure as necessary in cases of national security.. Public Safety (Duty to Warn): Disclosure regarding a serious threat of bodily harm or death to an identifiable person(s), as required by law. (Often referred to as TARASOFF) You have the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.(please enter initials) *
TECHNOLOGY: You understand we are using a multimedia platform and that a technical support team that may have access to your information supervises this platform. This venue has taken all precautions to protect your privacy and confidential information. The platform depends on various factors such as software, hardware and tools, either our own or those owned and/or operated by our contractors and suppliers. We do not guarantee that the platform will be uninterrupted or that it will be secure, consistent, timely or error-free. Abbie Gonzales MSW is not responsible for communication via cell phones, chat, email or fax. Precautions are used when utilizing these methods of communication. You will not hold Ms. Gonzales liable for any gathering or use of client information by these service providers.(Please enter initials) *
TREATMENT: I understand that Ms. Gonzales does not provide psychiatric health care and that I will not be given a prescription at all. I understand that if I participate in a session, that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery. If your therapist believes you would be better served by another form of psychotherapeutic service (e.g. face-to-face service), you will be referred to a psychotherapist in your area who can provide such service.(Please enter initials) *
FINANCIAL: Every session is $75 or a mutually agreed upon sum. Since the scheduling of an appointment involves the reservation of time set aside especially for me, a minimum of 24 hour notice is required for rescheduling or cancellation of an appointment.If for any reason a session is cancelled less than 24 hours prior, the full fee will be charged. Payments will be accepted via pay pal, cash app or mailed check prior to the session.(please enter initials) *
I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.(please enter initials) *
Full Name: *
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