Disclosure Statement & Informed Consent - 2024
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Mandy Attaway, MA, LMFT-A

mandy@mandyattaway.com  (817) 969-4643

Under Supervision by:

Gwen Bain, M.A. LPC-S, LMFT-S

gbain@bridgesofhope.net (682) 704-2601

Congratulations! You have just taken the first step towards change and healing. Whatever the reason may be that you are here, I am happy to join you in your journey. Please take the time to thoroughly read and understand the following important information so that we may have a mutual understanding from the outset of our relationship. Please let me know if you have questions or concerns. 

CLIENT/THERAPIST RELATIONSHIP: You and your therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. For the same professional reason, your therapist will decline any type of association through social media and can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. Gifts are not appropriate, nor is any sort of trade or barter for services.   

AVAILABLE SERVICES: I offer a wide array of counseling and therapy services, including individual, family, and couples services. Effective counseling is founded on a mutual understanding and good rapport between client and therapist. It is my intent to convey the policies and procedures used in my practice, and I will be pleased to discuss any questions or concerns you may have.   

RISKS AND BENEFITS: Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. I cannot guarantee these benefits, of course. It is my desire, however, to work with you to attain your personal goals for counseling.  

COUNSELING/THERAPY: I provide counseling/therapy services designed to address many of the issues my clients face. Your first visit will be an assessment session in which we will determine your goals and develop a plan of treatment together. Should you choose not to follow the plan of treatment provided to you by your therapist, a referral to another provider can be made or services to you may be terminated. 

The goal of Mandy Attaway is to provide the most effective therapeutic experience available to you. Mandy Attaway renders counseling services in a professional manner consistent with accepted ethical standards. If at any time for any reason you are dissatisfied with her services, please discuss this matter with her to determine if transferring to a more suitable therapist is right for you. If you decide together that other services would be more appropriate, she will assist you in finding a provider to meet your needs.   

Wellness is more than the absence of disease; it is a state of optimal well-being. It goes beyond the curing of illness to achieving health. Through the ongoing integration of our physical, emotional, mental, and spiritual self, each person has the opportunity to create and preserve a whole and happy life. Mandy's services are designed to provide her clients an integrated solution for their mind, body, spirit, and life in order to enhance their lives and resolve issues.     

APPOINTMENTS: Appointments are typically scheduled on a weekly basis and are approximately 50 minutes long. More frequent sessions or an intensive outpatient schedule are available if determined appropriate. If you must cancel or reschedule your appointment, I ask that you call my office at (817) 969-4643 at least 48 hours in advance, whenever possible. This will free your appointment time for another client. Appointments not cancelled within 48 hours will result in the regular session fee and must be paid prior to rescheduling. 

FEE SCHEDULE: Mandy works really intensely with her clients. That means you meet once per week, every week, until you reach your goals. This enables Mandy to really want to dig in and help you heal as quickly as possible. Most of Mandy's clients work with her for 6 to 8 sessions before they are ready for discharge. If there is a lot of trauma work, or any addictions, this could take a year or longer depending on your goals. With that being said, she doesn’t want you to be in therapy forever! Therapy is an investment into you, because you are worth it. Mandy wants to get you feeling better and arm you with the tools you need to be successful in living your best life as quickly as possible.

Sessions are typically 50 minutes long. Together, the client and counselor will make decisions concerning how often and for how long they should meet. Payment of the session fee is due in full at the booking of each session. Refunds can be issued 48hrs prior to the start of the session. The amount refunded will be the full session fee minus any credit card processing charges. 

FEE:  

Diagnostic & Evaluation Session (1st visit, Individual) $120.00

Diagnostic & Evaluation Session (1st visit, Couple) $130

Regular Office Visit (Individual) $120.00

Regular Office Visit (Couple) $130.00

Outside Office Work (including but not limited to:

Inpatient visits, Court, Collaborative law services,

Written Reports, Supervisors, Compliance officers, etc.)      $150.00/hour

Returned Check Fee  $40.00/per check 

A fee of $25.00 flat rate for up to 25 pages and any additional $1 per page thereafter will be charged for copies of any records requested by the client. Only full files will be provided, no partial files will be provided.

Patients may request a medical record summary the contents of which may be discussed and agreed upon by the client and Mandy prior to the summary written. Summary Fee: $150 (includes a session fee to discuss the content of the summary)

PAYMENT:  Payment of fees is expected when the appointment is booked. This guarantees and holds your appointment time.  

If you arranged a standing appointment time, your card will be kept on file and charged after the session has 

EMERGENCIES:  If you are experiencing a life-threatening emergency, call 911 or have someone take you to the nearest emergency room for help, or call a suicide hotline: 1-800-SUICIDE. It is the client’s responsibility to seek the appropriate resource in emergency situations. When I am out of town, you will be advised and given the name of another therapist.   

You may encounter a personal, time-sensitive matter which will require prompt attention. In this event, please contact my office regarding the nature and urgency of the circumstances. I will make every attempt to schedule you as soon as possible or to offer other options. Because clients may be scheduled back-to-back, it is not always possible to return a call immediately. However, we will make every effort to respond to this matter in a timely manner. If the situation arises after hours or on a weekend, feel free to leave a message on voicemail for me. I will return your call by the end of the next business day, if not sooner. 

CONFIDENTIALITY:  As an associate therapist, I follow all ethical standards prescribed by state and federal law. I am required to practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted below and in the Notice of Privacy Practices available in our office.   

Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse or neglect; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; criminal prosecutions; child custody cases; suits in which the mental health of the party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn or disclose; fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to my attention when we discuss this matter. By signing this Information and Consent Form, you are giving consent to me as a therapist to share confidential information with all persons mandated by law. You are also releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result.   

Therapists all work as a team for the benefit of your health and healing. Mandy may, from time to time, discuss and exchange information with each other therapists about you and your family while keeping your personal information private for the purposes of supervision or case consult in order to provide the best guidance and support to you and your family, as well as, scheduling and payment information. Information exchanges between the members of the team will not be disclosed to other nonaffiliated therapists outside of the practice, unless a written release has been signed by the client.  

When Mandy Attaway works with families, the confidentiality rules become more complicated. In the interest of the therapeutic and healing process, we encourage open disclosure between family members and couples. Mandy Attaway uses a firm no-secrets policy. If a spouse/partner tells the therapist something that may harm the other partner/spouse, or a family member, or may impede the progress of the therapeutic process, the therapist will discuss this with the client, and encourage him/her to disclose it, and cannot promise to keep it confidential. At the beginning of family therapy, those members designated by the therapist and the family will sign a release form to be made part of the therapy record. 

If you and your spouse/partner have a custody dispute, or a custody court hearing is scheduled in the future, Mandy Attaway will need to know about it. Her professional ethics prevent her from conducting therapy and custody evaluations. 

Because discussions between you and your therapist—and even the fact that you are in counseling— are confidential, if Mandy Attaway sees you in public, she will protect your confidentiality by greeting you only if you greet her first. 

TERMINATION/DISCHARGE FROM THERAPY: Discharge from therapy is a natural part of the therapeutic process and could happen at any time the client decides to discharge from therapy. Mandy utilizes a solution-focused approach that leads to faster discharge time frames for her clients. Throughout the course of therapy, Mandy will ask you if treatment is helping, and if you think you may be ready for discharge soon. This conversation helps Mandy to customize the therapeutic process for you by ascertaining what is working and what is not working. Mandy will not discharge you from active therapy without discussing it with you first. Your input is vital. Once you have met all your therapeutic goals and have a plan for the future, you are ready for discharge. Mandy also refers to this as graduation from therapy as it is something to celebrate. 

If Mandy has not heard from you in a month (4 weeks), she may close your file. She may assume at that time that you have resolved the problem and reached your therapeutic goals. Closing your file allows Mandy to open up your space for another client on the waitlist. 

If your file is closed, you are more than welcome to return to therapy at anytime! You will just need to schedule a 15-minute consultation with Mandy to see if she has availability, to discuss your needs and potentially redo any assessments depending on necessity, the length of time from the last session and the occurrence of any major life events during that time that may change the outcome of the assessments. Mandy will let you know if this is needed during the 15-minute consultation. 

If you know you will need a timeout from therapy due to life events, please let Mandy know either through email or text. This will help Mandy plan this stage of therapy with you so you can move forward confidently with the support you need. Depending on the length of time away from therapy, closing your file maybe necessary. As a former client, you are still welcomed to reach out to Mandy via email or text should you need anything.

DUTY TO WARN/DUTY TO PROTECT:  If my therapist believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to my Therapist to contact any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger. I also give consent to my therapist to contact the following person(s) in addition to any medical or law enforcement personnel deemed appropriate: 

Name

Their Contact Number

INCAPACITY OR DEATH:  I understand that, in the event of the death or incapacitation of the undersigned therapist, it will be necessary to assign my case to another therapist and for that therapist to have possession of my treatment records. By my signature on this form, I hereby consent to another Licensed Mental Health Professional, selected by the undersigned therapist, to take possession of my records and provide me copies at my request, and/or to deliver those records to another therapist of my choosing. 

COMPLAINT PROCEDURES: If you are dissatisfied with any aspect of our work together, please inform me immediately. If you feel that you have been treated unethically, by me or any other professional in my field, and you are not comfortable resolving the conflict with me, you can contact my Supervisor, Gwen Bain LMFT-S, LPC-S. Gwen Bain’s contact information is listed on the top of the first page. 

CONSENT TO TREATMENT: By signing this Client Information and Consent Form as the Client or Guardian of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in the Information, and Client Consent form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receiving mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time. NOTE: If you are consenting to treatment of a minor child, if a court order has been entered with respect to the conservatorship of said child, or impacting your rights with respect to consent to the child’s mental health care and treatment, I will not render services to your child until I have received and reviewed a copy of the most recent applicable court order.   


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