PURPOSE OF TREATMENT: The purpose of treatment is to support the client (you) in transformation and accomplishment of goals.
GENERAL PROCEDURES USED IN TREATMENT: Alder and Oak Counseling LLC (referred to as your, our therapists or we through this document) utilizes a variety of therapeutic modalities including, but not limited to, traditional talk therapy, cognitive behavioral techniques, experiential processes and mindfulness techniques.
PROCEDURE’S BENEFITS, LIMITATIONS, AND RISKS: As with any modality, there are benefits, limitations, and risks. Benefits include enhanced awareness and emotional understanding of yourself; improvement in your relationships with others; reduction in presenting symptoms; greater ability to cope with stress and work through difficulties; improved functioning in social, vocational, educational, and/or relational areas; strengthened self-cohesion and overall sense of well-being. Limitations and risks include disturbance of emotional and functional aspects of your life; no experience of change; feeling worse before feeling better; an increase in such feelings as grief, sadness, and anger; feeling better but having increased conflicts with others as you do things differently. Limitations may include the skills of the counselor and the capabilities and potentials of the client. The client has a right to question and/or refuse any therapeutic interventions, suggestions or directives at any time.
CONFIDENTIALITY: The information you give to your therapist during session is strictly confidential. It will not be divulged to anyone unless you have given your therapist written permission, with the following exceptions:
● Your therapist has reasonable cause to believe that you are in such a mental or emotional state as to be dangerous to yourself or another person or the property of another person.
● Your therapist suspects or has evidence that there is abuse to a child (under 18) or a dependent or disabled adult. Abuse can be classified as physical injury, sexual assault, cruel punishment or neglect.
● If your therapist is ordered by a court of law to disclose information
● Therapeutic services were sought or obtained to enable or aid anyone to commit or plan to commit a crime.
In order to provide you with the best possible treatment experience, therapists for Alder and Oak Counseling LLC participate in consultation and trainings with other professionals. Unless our therapists obtain written authorization, identification is not by name but by circumstance and steps are taken to protect identity for professionals providing support not affiliated with Alder and Oak Counseling LLC. Please respect the confidentiality of others seen or met in the counseling office or sessions.
Telehealth Responsibilities
(Telehealth refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of Telehealth is that services without being in the same physical location. This is helpful in ensuring continuity of care if someone moves, takes a vacation, or is otherwise unable to meet in person. It also takes less time. Telehealth, however, requires technical competence on both your therapist as well as you, the client, to be helpful. Although there are benefits of Telehealth, there are some differences between in-person psychotherapy and Telehealth, as well as some risks.)
● Risks to Confidentiality: Because Telehealth sessions take place outside of your therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. Your therapist will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for session where you will not be interrupted. It is also important for you to protect the privacy of the session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
●Issues Related to Technology: There are many ways that technology issues might impact Telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
● Efficacy: Most research shows that Telehealth is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely. There are some modalities that we will not be able to do, including EMDR and Sandtray.
Acknowledging COVID-19 Concerns and Liability
- I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
- I further acknowledge that Alder and Oak Counseling, LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Alder and Oak Counseling, LLC cannot guarantee that I will not become infected with the Coronavirus/Covid-19 or spread it to other people. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff, and other therapy clients and their families.
- I voluntarily seek services provided by Alder and Oak Counseling, LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
- I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
- I have not traveled internationally within the last 14 days.
- I have not traveled to a highly impacted area within the United States of America in the last 14 days.
- I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
- I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
- I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
- I hereby release and agree to hold Alder and Oak Counseling, LLC harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the counseling practice, or that may otherwise arise in any way in connection with any services received from Alder and Oak Counseling, LLC. I understand that this release discharges Alder and Oak Counseling, LLC from any liability or claim that
- I, my heirs, or any personal representatives may have against the counseling practice with respect to any bodily injury, illness, death, medical treatment, or
property damage that may arise from, or in connection to, any services received from Alder and Oak Counseling, LLC. This liability waiver and release extends to the counseling practice together with all owners, partners, contractors, and employees.
Electronic Communications
Your therapist will decide with you which kind of Telehealth service to use. You may have to have certain computer or cell phone systems to use Telehealth services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in Telehealth. You may need to contact your insurance company directly to find out what they cover.
Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach your therapist by phone. We will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach your therapist and feel that you cannot wait for a return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact during the absence, if necessary.
Confidentiality
We have a legal and ethical responsibility to make our best efforts to protect all communications that are a part of our Telehealth. However, the nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for Telehealth sessions and having passwords to protect the device you use for Telehealth).
The extent of confidentiality and the exceptions to confidentiality that we outlined in our Informed Consent still apply in Telehealth. Please let your therapist know if you have any questions about exceptions to confidentiality.
Appropriateness of Telehealth
We will let you know if we decide that Telehealth is no longer the most appropriate form of treatment for you. We will discuss options or referrals to another professional in your location who can provide appropriate services.
Emergencies and Technology
Assessing and evaluating threats and other emergencies can be more difficult when conducting Telehealth than in traditional in-person therapy. To address some of these difficulties, we will use your emergency contact identified in your Intake paperwork in the event of a crisis or emergency to assist in addressing the situation.
If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call your therapist back; instead, call 911, NM Crisis Line at 1-855-662-7474, Santa Fe Crisis Response 1-800-273-8255, or go to your nearest emergency room. Call your therapist back after you have called or obtained emergency services.
If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the Telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call your therapist on the phone number I provided you (Diana Zumas, LPCC at 505-231-7157, Casey Dexter, LCSW at 505-257- 8554, Vanessa Torres McGovern, LPCC at 207-233-3169 or Josephine Tejal Murray, LPCC, 505-366- 8984).
If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.
Fees
The same fee rates will apply for Telehealth as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in Telehealth sessions in order to determine whether these sessions will be covered.
Records
The Telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. We will maintain a written record of our session in the same way we maintain records of in-person sessions in accordance with our policies.
FEES, PAYMENT AND APPOINTMENTS:
● $100 (including tax) for 60 minute session
● Please provide at least 24- hour notice to cancel a session. Missed appointments without 24 hour notice may be charged. Messages can be left at 505-231-7157 for Diana, 505-257-8554 for Casey, 207-233-3169 for Vanessa Torres McGovern or 505-366-8984 Tejal 24 hours a day.
● Contact outside of sessions is available on a limited basis as your therapists schedule allows. For occasional support, the first 15 minutes are free. Beyond that time, the same rate for in-person sessions apply.
● Our therapists may make appointments and send general information via text and email. It is acknowledged that these are not always guaranteed confidential modes of communication.
● Our therapists make the greatest attempt to return all messages within 24 hours. If a message is left end of week, it may be returned by the beginning of the next week.
● Payment can be made by check, cash or credit card prior to or at the time of session. ● A 3.5 % + $0.15 service fee will be charged for credit card payments
● We reserve the right to change fees with 30 days notice.
● By signing this document you are agreeing to pay for any services rendered.
TERMINATION: You can revoke your consent for treatment and terminate at any time. If you do not revoke your consent, it will automatically expire one year later from the date indicated on the consent form.
EMERGENCIES: Although our therapists will be as supportive as possible in times of crisis, the nature of this practice is that of outpatient services. This assumes that all clients are self-responsible and not in need of day-to-day supervision. Our therapists cannot assume responsibility for your daily functioning like a hospital or inpatient facility can. By signing this document you agree that if you feel that you are in crisis or having an life threatening emergency you will dial 911, contact the Crisis Response of Santa Fe at 505-820-6333, or go to your local hospital. As a part of your self-care and healthy functioning, Alder and Oak Counseling LLC supports and encourages you to develop and utilize a support system outside of therapy that you can rely on if the need arises.
TREATMENT DECISIONS: You are in charge of your own therapeutic process, just as you are in charge of your own life. Our therapists are working in your interests. You can determine what your goals are and your therapist’s role is to help you reach them. We both agree that your goals can be changed at any time.
Alder and Oak Counseling LLC 505-257-8554 intake@alderandoakcounseling.com
CLIENT COUNSELOR RELATIONSHIP: The therapist/client relationship is unique in that it is exclusively therapeutic. In other words, it is not appropriate for a client and a counselor to spend time together or to attend family or religious functions. The purpose of these boundaries is to ensure that you and your therapist are clear in the roles for your counseling process and that your confidentiality is maintained. Additionally, if there is ever a time when you believe that you have been treated unfairly or disrespectfully please talk with your therapist about it. We want to address any issues that might get in the way of your counseling. This includes administrative and financial issues as well.
Please feel free to talk with your therapist about any questions you might have about this consent.
CREDENTIALS: Diana Zumas is a Licensed Professional Clinical Counselor in the State of New Mexico (license #0180451) and a Licensed Professional Counselor with the State of Arizona (license #LPC- 15477).
Casey Dexter is a Licensed Clinical Social Worker in the State of New Mexico (license # C-10046).
Vanessa Torres McGovern is a Licensed Professional Clinical Counselor in the State of New Mexico (license # CCMH0210241).
Josephine Tejal Murray is Licensed Professional Clinical Counselor in the State of New Mexico (license # CCMH0200831).
I have read this entire Consent for Treatment and I understand and agree to these arrangements and request the services of Alder and Oak Counseling LLC.