Informed Consent for Journey Into Wellness Counseling

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Julie Wells LCSW, CP, TEP 26133 US Hwy 19 N #310 Clearwater, FL 33763
(727) 688-5800 Fax (727) 286-9640 journeywellness@aol.com

Please check that you understand each *

I am a competent adult voluntarily seeking mental health assessment and/or counseling for myself and/or my minor child.

I understand that, although mental health counseling is expected to be helpful in resolving my problems, no guarantee has been made about the usefulness or effectiveness of treatment.

Required

APPOINTMENTS AND AVAILABILITY *

Services are scheduled by appointment. A fee of $150 will be charged to my credit card on file for missed appointments or those canceled with less than 24 hours notice. I will be charged on the morning of the appointment, not after services are provided.

A clinical hour is 50 minutes that allows time to set our next appointment, etc. To maximize benefit, I will arrive on time as much as possible.

If I have not been seen in this office in 90 days, my file will be moved to inactive.

Required

FEE AGREEMENT AND CANCELLATIONS *

The fee is $150 for a 50-minute session. These fees are set in accordance with the usual and customary charges given credentials and experience.

I understand that full payment must be made in either check, cash, or credit card through IVY Pay at time the services are rendered. A link will be sent prior to the first session. Co-payment is due at the time of service unless other arrangements are made in advance (or full payment, if insurance is not used or deductible is not satisfied). Receipts will be provided upon request to allow reimbursement with HSA or insurance provider. In the event insurance does not pay for my treatment, I will be responsible for payment.

I am aware that I need to cancel any appointments at least 24 hours in advance or I will be charged the full session fee ($150) for the missed appointment, except in an emergency situation. It is assumed that without a phone call, if I am more than 15 minutes late for a session that I will not be attending.

I understand that full payment for my FIRST initial assessment appointment must be made before reserving my initial appointment.

Other:

Required

CONFIDENTIALITY

Because of the laws of this state and the guidelines of the therapist's profession, these privacy rules will be followed:

All information will be held confidential and privileged unless the psychotherapist has suspicion of neglect or abuse of a child, a senior citizen or a disabled person, in which case a report will be made as required by law to the appropriate law enforcement and social welfare agencies.

All information will be held confidential and privileged unless I report suicidal or homicidal ideation, intent or plan, in which case a call to authority and/or a report will be made as required by law to the appropriate law enforcement and social welfare agencies

Other information may be released in accordance with the Heath Insurance Portability and Accountability Act as described in this office’s Notice of Privacy Practices. I may have to release your records when ordered to do so by court subpoena. However, Julie Wells will discuss this with you beforehand and request a written release of information from me, if she judges this to be in my best interest.

Required

MINORS *

While encouraging parental involvement, we must also provide adolescent patients with an opportunity to speak privately with a health care provider. Although the client is granted the right to inspect the chart, the minor will give written signed consent before a parent will be allowed to access the chart of a minor before, they reach age 18. This practice confirms the minor’s independent rights to maintain confidentiality of his or her therapy and mental health treatment records. If found to be in best interest of minor’s treatment plan goals, updates on treatment goal progress may be shared, upon request, to the non-custodial or non-attending parent of children, under the age of 18.

Julie Wells cannot be an advocate for either side of custody determinations, unless required by state and federal mandatory reporting laws, and will not be able to testify as an expert witness regarding issues such as visitation, custody or fitness to parent.

Required

LEGAL/COURT INVOLVEMENT *

I understand that if I enter into treatment with Julie Wells, I am agreeing not to involve Journey Into Wellness Counseling Services in legal/court proceedings or to attempt to obtain records of treatment for legal proceedings. This prevents misuse of my treatment for legal objectives. The goal is to support me in achieving therapy goals, not to address legal issues that require an adversarial approach.

In situations requiring court involvement, the fee is $750 per hour for court appearances and $750 per hour for preparation for court testimony including, but not limited to, consulting with attorneys, reviewing the file, report/letter writing and time spent traveling to court and waiting to testify. In addition, since an entire day of clients would need to be cleared for attendance at court, a full day of 8 hours @ $550 per hour for each day of court or deposition request will be charged. There are additional fees for parking and mileage. A retainer for court expenses will be due and payable a minimum of two weeks prior to a scheduled court appearance. In the event of a settlement or cancellation of the trial/hearing with less than 48-hour notice, a charge will be levied for those hours originally set aside for the trial/hearing. These services are not reimbursable by your medical insurance.

Required

POSSESSION OF A WEAPON OR FIREARM *

I understand that no weapons are allowed inside the counseling office. Any weapon, whether permitted for concealed carry or not, must be left in the vehicle or at home. Failure to do so will forfeit the session and future sessions will have to be reevaluated.

Required

GRIEVENCE PROCEDURE

If at any time you are dissatisfied with your treatment, please discuss your concerns with me directly so we can work together to resolve them. If, after doing so, you would like a referral to a different therapist, I would be happy to assist you. If you ever have serious concerns that are not resolved successfully with me directly, the complaint will be referred to the respective licensing and/or Certification Boards such as the Florida Department of Health.

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CONSENT TO TREAT: By signing below, I am consenting to engaging in a therapeutic relationship with Julie Wells LCSW9966, Licensed Clinical Social Worker. I have read and have been offered a copy of these policies and agree to full responsibility for all expenses incurred during my treatment with Julie Wells LCSW9966. I understand that I have a right to withdraw from treatment at any time. The nature of treatment, my rights as a client, and the limitations in confidentiality has been explained to me. *

Full Legal Name *

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