INFORMED CONSENT AND COUNSELING AGREEMENT
It is important that you read this carefully before our first session. We can discuss any questions you have at that time.
We accept only cash, check and credit card (including HSA) for payment. The fee for each 50-minute, in-person session is $130.00. Unless we make other arrangements, fees are the responsibility of the client and are payable at the beginning of each session. We will file your insurance claims for you, but you are ultimately responsible for the services provided.
CONFIDENTIALITY, PRIVILEGE, AND PRIVACY
Within our intake packet, we provide information about the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA provides privacy protections and client rights regarding the use and disclosure of Protected Health Information (PHI PHI is used to manage your treatment, handle payments, and facilitate health care practice operations. HIPAA requires that you be provided with a Notice of Privacy Practices. Your Protected Health Information, treatment, and professional record are confidential except as otherwise noted in this document.
EXCEPTIONS TO CONFIDENTIALITY, PRIVILEGE, AND PRIVACYOver the past few decades, the courts and legislatures have set forth certain exceptions to confidentiality and we may be mandated by law to disclose certain material. For example, we are mandated to report any suspected child or elder (vulnerable adult) abuse; we must also intervene if we feel you are in imminent danger of harming yourself or others. In certain cases, when we am subpoenaed or court ordered to produce information, we may have to comply with such mandates. Unless prohibited by law, we will typically make efforts to contact you before turning over information in response to a subpoena or court order. You have the right to revoke a previously authorized release of information.
In regards to child abuse, if we have reason to suspect, on the basis of our professional judgment, that a child is or has been abused, we are required to report our suspicions to the authority or government agency authorized to conduct child abuse investigations. We are required to make such reports even if we do not see the child in our professional capacity. We are also mandated to report suspected child abuse if anyone tells us that he or she knows of any child who is currently being abused.
Also, if a client files a complaint or lawsuit against us or makes negative false statements about our practice or our clinicians, we may disclose relevant information regarding that client in order to defend ourselves. Additionally, if payments are delinquent, we may disclose needed information to a collection agency or attorney. The client is responsible for all costs associated with the collection. With your written permission, we may discuss your case (e.g., with other health care providers) or release your Protected Health Information to the individuals or entities you authorize.
ETHICS GUIDELINES We adhere to the American Counseling Association Code of Ethics.
LEGAL PROCEEDINGS We typically do not act as an expert witness in litigation and court proceedings. If you are in a lawsuit and you and your attorney decide to call one of our clinicians as a witness, we will charge for the time away from the practice in accordance with our normal hourly rate of $100.00 ($800.00 retainer is required prior to court appearance). This includes travel and preparation. If you are involved in or contemplating litigation, you may wish to consult with your attorney to determine whether your counseling communications may be protected by the professional counselor-client privilege law or whether such communications may be open to the other side in the lawsuit.
Psychotherapy and counseling is a major commitment on the part of the therapist and the client, requiring significant effort from each party. The client agrees to voluntarily attend all scheduled sessions, bring issues of concern to discuss, reflect on material between sessions, and pay for sessions in a timely manner. The therapist agrees to be present to the client, provide a safe arena for discussing issues, formulate a plan of action for addressing issues, and help the client find solutions to his or her problems. Considering the substantial commitment of time, money, and energy therapy requires, as well as its personal importance for your life, decisions about therapy deserve careful consideration.
Psychotherapy and counseling can have risks. Therapy often involves exploring unpleasant aspects of life so you may experience feelings like sadness, guilt, shame, frustration, anger and loneliness. On the other hand, psychotherapy has been shown to have many benefits. Therapy often leads to solutions for specific problems, significantly reduced distress, and improved relationships. Of course, there are no guarantees of what you will experience. Achieving good results from your therapy will depend on your full engagement in the process and on your motivation to change.
If you have questions of any kind, about your therapy or my procedures, we should discuss them whenever they arise. If our discussion does not satisfy you, we will be happy to help you set up a meeting with another mental health professional for a second opinion.
To make appointments, clients should call 859-278-3456. In order to avoid a cancellation fee ($75.00), please give 24 hours notice of change. No fees will be charged for missing an appointment due to emergencies. Work conflicts do not qualify as emergencies.
Therapy sessions are typically 53-60 minutes long unless another arrangement is made prior to the appointment. The frequency and regularity of therapy sessions is important for the effectiveness of treatment and for practical reasons. If the frequency and/or scheduling is not working for you, it is your responsibility to alert us so that another alternative can be arranged.
Clients under the age of 18 will need the permission of a parent or guardian to receive services. The parent or guardian is responsible for all fees incurred by the minor client. The parent or guardian also has the right to request a copy of the minor client's health record. That record will include all intake information and psychotherapy session notes. While this is required by law, our clinicians believe and understand that the best form of therapy includes the expectation of privacy.
In keeping with generally accepted standards of practice, we frequently consult on a confidential basis with other mental health professionals regarding the management of cases. The purpose of consultation is to assure quality care. Every effort is made to protect the identity of clients.
CONTACTING US BY PHONE
When we are unavailable to answer telephone calls directly, you can leave a message on our work phone, 859-278-3456. No one other than myself can access these messages. Messages are checked regularly and calls returned at the first opportunity between the hours of 9am and 5pm. Please always leave your number and best time to call. If you are unable to reach us in the event of an emergency, contact your family physician or go to the nearest emergency room.
CONTACTING US BY EMAIL AND/OR TEXT
We use text and email communication only with your permission and only for administrative purposes. That means that email and text exchanges with our office should be limited to things such as setting and changing appointments, billing matters, and other related issues. Please do not email our clinicians about clinical matters.
Therapy is a professional relationship focused on the client's needs. For this reason, we limit contact with clients to matters directly related to therapy.
Treatment ends when the therapist and client agree that therapy goals have been met. The client may terminate prior to this time with a minimum of one full session's notice. If the client provides 24-hours' notice, the client will not be billed if the client decides to terminate.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.