We understand that therapy begins with an evaluation of our relationship, past and present. While Wendy Pearson, FNP-C LMFT, is deciding whether she is the appropriate therapist for me, I will also decide whether to begin therapy with her. I understand that because of the commitment of time and money, plus the potential impact on us and others, it is important to make an informed choice when seeking therapy.
I have read and understand the potential limits of confidentiality, including those imposed by the Medical Wellness Center of Georgia’s policies and by state law, and I have received a copy to keep. I understand that information discussed in therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving others. I agree not to subpoena Wendy Pearson to testify for or against either party or to provide records in a court action.
I understand all policies as related to appointment cancellation, rescheduling, and no shows: if you do not show for you appointment, cancel, or do not reschedule within 24 hours of your appointment time, you will be billed an administrative fee of $25.00. The patient and/or guarantor is responsible for all charges of services when rendered. I accept these as conditions for entering therapy with Wendy Pearson. I understand the limits and benefits of using a cash option to pay for therapy. I understand that the initial visit will be charged at $125.00 with subsequent follow up appointments agreed upon by the client and will be charged $100.00.
I have been given the opportunity to ask questions and discuss confidentiality and disclosure policies with Wendy Pearson.
As a rule, I will keep the information you share with me in our sessions confidential, unless I have your written consent to disclose certain information. There are, however, important legal exceptions to this rule that are important for you to understand before sharing personal information with me in a therapy session. The following are legal exceptions to your right to confidentiality:
1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
2. If I have good reason to believe there is abuse and/or neglect of a child or adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to this and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
By signing below, I agree to accept mental health services from Wendy Perason, FNPC; LMFT. and accept full responsibility for payment for such services.