affirm that I have read and understand the information stated in this agreement.** I will discuss the goals, objectives, methods, and time frame of my treatment with my counselor, understanding that these may be modified as therapy progresses. I am aware that I have the right to refuse treatment or to terminate counseling should I choose. I understand I can discuss the nature of the treatment to be employed along with the risks and alternatives. Furthermore, I limit my counselor’s use of any information which can in any way identify me to others, unless I have given my specific written permission.
I understand that therapists at Central DuPage Pastoral Counseling Center are mandated reporters. The limits of confidentiality do not include discussion of homicide, suicide, child abuse/neglect (past or present), elderly abuse/neglect, abuse/neglect to any other vulnerable population, supervision or consultation with colleagues, responses to court-ordered subpoenas, other exceptions identifiers in the HIPAA information. Further, I understand that according to the Patriot Act, federal officials conducting national security investigations may access my records without my knowledge. The law supersedes the ethic of confidentiality.
I agree to pay for the session (or insurance co-pay) at the time of service. I agree to pay for any outstanding balances which may be billed to me or charged to my credit card, understanding that failure to do so may result in collection action or credit bureau reporting.
At this time I consent to work toward the achievement of the objectives with my counselor. I have read and understand the HIPAA psychotherapist/client services agreement. It is without any pressure or coercion that I sign this consent.