Consent to Treatment (Lumin y BLTFC English)

By signing this document I

Name *

First Name Last Name

confirm that I agree to participate in counseling (psychological therapy) with Aurolina Valdés, LMFT and confirm that I agree with all the following:

I understand these services are voluntary and I am in no obligation to accept them. *

I understand.

I understand that the number of sessions is something that Aurolina Valdés and I will decide together and that I can end treatment at any time without any repercussion or consequence. *

I understand.

I undestand that, while I am an active client of either Lumin Edcuation or Bachman lake Together, these services are completely free to me. *

I understand.

I understand that even though services are free to me it is my responsibility to cancel appointments at least one day before. This is a courtesy for Aurolina and for other people who might be in the waiting list and in need of services. *

I agree to make my best effort not to cancel appointments on the same day and to inform Aurolina at least one day in advance so she can plan to see other clients.

I understand that if I miss 2 appointments or if I do not cancel them the day before Aurolina Valdés might choose to close my case to provide services to clients in the waiting list. *

I understand.

FOR LUMIN EDUCATION CLIENTS: because this is a home visitation program you have the right to chose for sessions at home, in my office or through video. Please choose your preference below: *

I authorize sessions at home (only when Social Distancing norms allow it). I understand that Aurolina Valdés will never pay me a surprise visit and that she will only visit when we have agreed for the best time and day for our session. I do not authorize sessions at my home. I do not participate in Lumin Education .

FOR BACHMAN LAKE TOGETHER CLIENTS: *

I authorize sessions in Aurolina's office at Lumin/Bachman Lake Together (When Social Distancing norms allow it). I understand that we need to schedule and appointment as there are no walk-in appointments. I do not accept or I have no means to go to Aurolina's office so we will only work through tele-health or video sessions.

For all clients: Due to the COVID-19 Pandemic and the uncertainty of future quarantine restrictions you must agree to receive services via tele-health or video sessions since it is the only way Aurolina can continue to provide support during quarantine periods. *

I understand and accept that it is necessary to authorize video services since it is the only way for Aurolina to provide care during health crises. I understand that there will only be video sessions when we agree on them and there will never be unscheduled or surprise video calls.

I am aware that our sessions will be from 45 minutes to one hour long. *

I agree.

I understand that Aurolina and I will agree of how frequently we will meet and that she will share her professional opinion with me base on my emotional needs and also the amount of clients she is authorized to support every month by Lumin Education and Bachman Lake . *

I understand and agree.

I understand that although the details of my treatment are confidential, Aurolina Valdés will only share with teachers and administration at Lumin o de Bachman Lake the minimum necessary information to justify my treatment (general concerns, reasons for treatment, my involvement and commitment to our sessions, progress, etc). *

I agree.

Aurolina Valdés has explained to me the limits of confidentiality and I am aware that BY LAW she has to report if she ever has information that leads her to believe that a child has been/is been abused or neglected, if I may hurt myself or another person. *

I understand the limits of confidentiality.

Aurolina Valdes has informed me that I can read her Privacy Practices in the link below to learn about my rights as a client. She has also informed me that there is a printed copy in her office and that I can request a copy for myself.

If you would like to read my Privacy Practices right now please use the link below (When you are done reading, close that web page to return to this document. sadly, there is a posibility that the information you already entered could be lost)

Privacy Practices

I authorize Aurolina Valdés to send me non confidential texts and appointment reminders to the following cell phone number: *

Area Code Phone Number

My signature below confirms my consent to receive counseling or psychological therapy. *

Clear

Effective date for authorization: *

Date

Informed Consent for Counseling (psychotherapy) for participants of Lumin Education and Bachman Lake Together.