Family & Addiction Counseling LLC Consent Forms
Please complete your online consent forms below to give us permission to care for you. Call (808) 494-6066 if you have any questions or concerns.
Email address *
Informed Consent For Treatment
I consent that I am at least 18 years old and have legal authority to act for "Patient" who may be treated as a patient by Family and Addiction Counseling LLC and its agents located at 1888 Kalakaua Ave. C312, Honolulu, Hawaii 96815.
Patient's Full Name *
Your answer
Emergency Situations
Counseling sessions are available at selected times throughout the week. If for some reason you are unable to contact me, you may obtain assistance by calling 911, the Crisis Help Line at (808) 832-3100 (Oahu) or 1-800-753-6879 (off-island), or by going to your local hospital emergency room.
Provider Services
Your therapist will primarily provide individual or family cognitive, behavioral, integrative, outpatient therapies. If you wish, your therapist will explain any style and technique to you.

Your therapist reserves the right to deny services to individuals whose concerns are beyond the scope of competence as well as to any individual that abuses or misuses services in any manner, e.g. non-compliance with treatment, frequent missed appointments, delinquent payment, etc.

If your therapist is unable to offer you services for your specific needs, we will discuss other local treatment options and possible referrals with you.
The Counseling Process
In order for therapy to be effective, it is necessary for both counselor and Patient to take an active role in the counseling process.

Participation involves being open to each other's thoughts and ideas, being honest with each other, discussing concerns about the process, completing outside assignments when appropriate, and providing ongoing feedback to the therapist about the process.

While counseling is often beneficial for many people, some people may not find therapy helpful. The counseling process can also evoke strong feelings and sometimes produce unanticipated change in one’s behaviors, thoughts, and feelings, family members, and friends.

In order for you to maximize your experience, it is helpful to discuss with your therapist any questions or discomfort you may experience during therapeutic process.

You have the right to ask any questions, at any time, about what occurs during therapy.

You have the right to refuse the use of any therapy technique.
You and your therapist will collaborate on your frequency of sessions, number of sessions, goals, and type of counseling throughout the counseling process.

You and your therapist may re-evaluate the frequency of your sessions as situations arise and/or as you move towards your goals.

We routinely check for voice and text messages during regular business hours and usually all calls are returned within 24 hours.

If your therapist is not available immediately by phone, messages may be left at (808) 494-6066.
You have the right to decide not to enter therapy with your therapist and to end therapy at any time.

Your therapist recommends for a list of other providers in your community.

You are responsible for any outstanding payments for services received.
Under most circumstances, all information about you, in written or verbal form, obtained in the counseling process (including your identity as a client) will be kept ethically and legally confidential. Information will not be disclosed to any outside person(s) or agency without your written permission except in certain situations, which include, but are not limited to:

If you are determined to be in imminent danger of harming yourself or someone else.

If you disclose abuse or neglect of children, the elderly, or a disabled person(s).

Diagnosis and services shared with your insurance company to collect payments.

To qualified personnel for certain kinds of audits or evaluations.

In cases where the client signs a release of information form.

In court proceedings and where otherwise legally required.

Information necessary for supervision or consultation.

Information for business operations including accounting, data management, and laboratory testing systems.

Any information that you also share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court. The above is considered a summary. If you have questions about specific situations or any aspects of confidentiality, please feel free to discuss your concerns with your therapist. You may also contact American Psychological Association at
Fees and Billing Schedule
One-hour psychotherapy sessions cost $180 per hour. If you have selected to use an insurance carrier we accept, your therapist will bill your plan directly. Co-payments can be made with cash, credit card, or a personal check.

If your insurance has an unmet deductible or denies payment for any reason, client is responsible for the total amount due. Therapy is a significant personal and financial commitment. Please do not hesitate to discuss financial matters with your therapist.
Canceling Appointments
If you need to cancel or change an appointment, please give more than 48 hours notice to your therapist using our text message scheduling system.

If you cannot let us know more than 48 hours in advance, you will be charged $36.00 for the scheduled session using your credit card.
Certification *
Signature of Patient / Guardian *
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