Informed Consent- Information, Authorization and Consent to Treat
This form is designed to give you information about my background and credentials and to provide some structure for our sessions. Please take your time reading this agreement and express any concerns or questions directly to me. It is important that we communicate clearly. I will ask you to sign this form to verify that you understand and agree to operate within these terms in our therapeutic relationship.
I am a National Certified Counselor, a Licensed Professional Counselor in Tennessee and Georgia, and a Mental Health Service Provider in Tennessee. I have never and will not accept insurance of any kind. Assigning you a diagnosis today that will follow you on your medical record for the rest of your life presents me with a personally unacceptable ethical dilemma. If you need to use insurance, I will help you find another therapist.
Self-care and conscious living are personal foundations I attempt to incorporate in each session. Some clients only need a few sessions to reach their goals, while other issues require several months or longer to process. It is not my intention to keep you in therapy any longer than is optimal for your wellbeing. I do request that clients participate in a closing session when therapy is concluded to process the ending of our work together. Please keep in mind that your work in therapy may impact your current relationships; there is no guarantee that psychotherapy will be helpful to you; and your emotional pain may intensify within the healing process. Your progress in therapy is indicated more by what you practice between sessions than what happens in the sessions.
Confidentiality is essential in our work. Publicly I cannot acknowledge you unless you speak to me first to ensure your privacy. I am also ethically restricted from connecting with you via Facebook, Instagram, Twitter, or any other form of social media or accepting gifts so that we do not enter into a dual relationship beyond client/therapist. I may consult with professional colleagues about our work without asking your permission between our appointments. I will never use your name and may change some details about you to protect your privacy.
I will keep confidential anything you say to me with the following exceptions: 1) You direct me to talk to someone and sign a release; 2) I determine that you are a danger to yourself or others; 3)I am ordered by a judge to disclose information; or 4) You report knowledge or suspicion of physical or sexual abuse or neglect of a minor or an adult who cannot care for themselves. I am required to report these cases of abuse or neglect to the appropriate state agency.
If you are seeking counseling to find an expert witness for a court case, I am not a willing witness and I will seek legal representation to avoid court appearances. I am happy to help you find a therapist who does enjoy presenting expert testimony. Therapy sessions are used as a safe place to make full disclosures of information that are confidential in nature The nature of legal proceedings makes it difficult to maintain confidentiality. Should there be a legal proceeding such as divorce, custody disputes, injuries, lawsuits, etc. your signature below agrees that neither you or your attorney will ask me to testify in court or at any other proceedings nor will disclosure of psychotherapy records be requested.
Session Length and Fee
Typical sessions are 50 minutes weekly at $150.00 per session. 75-minute sessions are $225.00. All fees are to be paid at the time of service by cash, check ($15 check return fee), or credit card. In the event that you are unable to keep an appointment, please notify me by phone or text (not email) 24 hours in advance. Without notice, you will be billed for the missed session except in the event of an emergency or illness. Services rendered outside of session time are billed separately as my services include: phone consultation, emails, requests for documentation, or letter writing. I can not guarantee a successful treatment outcome with a particular Client. Therefore, fees are paid as a consideration for the specialized therapeutic interventions and not for particular results for any client.
Contact Information and Technology
Please initial each option to give me permission to call you, send a text, email or leave a voice message:
I will not leave a message with a person unless you agree by writing their name below and information below (Name, Relationship example: Jane Doe, Sister).
Confidentiality of Email, Text, Cell Phone, and Fax Communication
PLEASE ONLY USE MY SECURE EMAIL,
. This email account will encrypt our communication, keeping it secure and confidential.
It is important for you to know that landlines, cell phones, texts, faxes, and emails may not be completely secure or confidential means of communication. Texts and emails are only to be used for setting, changing, and confirming appointments or changing contact information. Personal and clinical concerns should not be addressed via email or text. Do not include personal identifying information such as your birth date, or personal medical information. I am required to keep a copy of your texts, emails, and a summary of our phone conversations in your records. Your records and my fax machine are kept secure with two locks. I will retain your records until seven years after the last date of service or three years after a minor reaches 18, whichever is later.
Be aware that the apps or websites that I recommend may collect and sell user information without your permission. Please do not provide any personal identifying information.
I do my best to respond promptly to voice mail messages or texts (No emergency emails, please.) within 24 hours of your call. I do not respond to emails Friday evening through Sunday at noon. IF YOU ARE IN A CRISIS WHEN I AM UNAVAILABLE,
-CALL 911, or
-HAVE SOMEONE DRIVE YOU TO THE EMERGENCY ROOM OF YOUR CHOICE.
Confidentiality and Limitations of Distance Counseling Options
Video or phone sessions have limitations compared to in-person sessions. Video sessions allow for face-to-face interactions, but I may miss visual and audio cues in the therapy process. Please help me by sharing information about your posture, physical sensations, and emotional responses during our sessions.
Psychotherapy with me is not a substitute for medication under the care of a Psychiatrist or Doctor. I follow the laws and professional regulations of the State of Tennessee and the State of Georgia. Your psychotherapy treatment will be considered to take place in your state of residency, Tennessee or Georgia.
Every effort will be made to keep all information confidential. If we are working online together, I ask that you determine who has access to your computer and electronic information from your location(s). This would include family members, co-workers, supervisors, and friends. Please use a computer that you know is safe so that confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails and turn off all notifications.
If you and I are unable to connect or are disconnected during a session due to technological breakdown, please try to reconnect within 10 minutes. If we are unable to reconnect after 10 minutes, we will communicate via text. I will direct you to my backup video platform or we will continue by phone.
Typing your name below serves as your signature and indicates your agreement to abide by the terms of this Informed Consent document. Please type your name below to sign.
Please indicate the date of your signature below.
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