Informed Consent to Counseling

If patient is a child sign: CONSENT FOR TREATMENT FOR A MINOR
If patient is an adult sign: TREATMENT AGREEMENT FOR AN ADULT

This agreement contains important information regarding professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment and health care operations. The law requires professionals to obtain your signature acknowledging that you have been provided with this information. Although these documents are long and at times complex, it is very important that you read them carefully.

Mental Health Services:
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the clinician and client, as well as the particular problems you are experiencing. There are many different methods to deal with the issues you hope to address. Psychotherapy is a collaborative process where the client is cared about, understood, and empowered. In addition, the client’s sense of safety and trust are both very important aspects of the therapeutic relationship and process. All of these fundamental characteristics are crucial elements of the counseling process and are encouraged to be openly expressed by the client. It is through this process that the client will be able to grow, learn, and build on strengths in order to re-establish a sense of personal balance.

Psychotherapy can have both benefits and risks. Since therapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience. It is important to remember that when making changes in one’s life can take time, energy, and effort.

Meetings:
Therapy sessions will usually consist of one 45 – 50 minute session (one appointment hour of 45 – 50 minutes duration) per week at an agreed upon time, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation {unless we both agree that you were unable to attend due to circumstances beyond your control}. It is important to note that insurance companies do not provide reimbursement for cancelled or missed appointments. The meeting/appointment fee is equal to your agreed upon session rate.

There is no set time for how long therapy may ast; this is determined by mutual agreement between the clinician and the client. The length of services varies depending on the client’s needs and symptoms. It is important that when you are thinking about ending services that you discuss that with your clinician in advance of doing so. This is an important phase of treatment, as issues regarding separation and closeness are important themes within our lives and therapy. We encourage you to discuss this area openly.

Counseling is based on the relationship you develop with your clinician. Every case is unique; however you can expect the following: Information and education about what you may be experiencing; homework is a vital part of making the most of your counseling process and may be given; FCC is client-centered; therefore topics will revolve around you and your concerns; you may be asked questions and there is an expectation that you will openly share as we work together to identify thoughts, feelings, and behaviors.

Professional Fees:
In addition to weekly appointments, the therapist reserves the right to charge for other professional services you may need including report writing, telephone conversations lasting longer than 15 minutes, preparation of records or treatment summaries, and the time spent performing any other services you may have requested of the therapist. If you become involved in legal proceedings that require therapist participation, you will be expected to pay for all professional time, including preparation and transportation costs even if the therapist is called to testify by another party. Due to the difficulty of legal involvement, the Family Counseling Center will charge $1500 for each Subpoena received and occurrence required. Fee includes preparation and attendance at any legal proceeding and is required to be paid prior to court date (Subpoena Required for Court Attendance).

Billing & Payments:
The Family Counseling Center does not accept insurance benefits; therefore clients are expected to pay out of pocket for services rendered. Client will be expected to pay for each session at the time it is held, unless agreed otherwise. A Superbill will be provided upon request for non-participating provider insurance benefits. Payment schedules for other professional services will be agreed to when they are requested. The Family Counseling Center reserves the right to impose a 1% per month (12% APR) interest charge on all accounts that are not paid within 60 days of the billing date. The Family Counseling Center reserves the right to submit delinquent accounts to collections, with any fees associated being the sole responsibility of the client or parent/guardian if the client is a minor. The fee for a returned check due to insufficient funds is $30.00.

Cancelled & Missed Appointments:
A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled without 24 hours notice, the clinician may charge you a missed/cancelled appointment fee equal to your agreed upon session rate. For parents who send their child to an appointment without parental supervision, please be aware that you may be charged a missed appointment fee if your child misses the appointment without providing 24 hours notice. It is important to note that insurance companies do not provide reimbursement for cancelled or missed appointments. The missed/cancelled appointment fee is equal to your agreed upon session rate.

Contacting your Clinician:
If you need to contact your clinician, please call the main office to leave a message and your call will be returned as soon as possible. After hours, holidays and/or weekends phone calls will be returned the next business day. The Family Counseling Center and your therapist do not provide emergency services and all office hours are by appointment only. Availability may include day, evening, and weekend hours as determined by your therapists schedule. Although your counselor may permit contact via text/email for administrative issues such as appointment changes and/or confirmations, billing questions, paperwork requests…it is not permitted to use these methods for therapeutic purposes or if in crisis. In the event of an emergency, the client is to call 911, go to the nearest emergency room, or call crisis intervention for the county residing in.

Limits on Confidentiality:
The law protects the privacy of all communications between client and a mental health professional. In most situations, professionals can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities as follows:

• Clinician may find it helpful to consult other health and mental health professionals about a case. During consultation, the therapist makes every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. If you do not object you will not be told about these consultations unless it is important to the counseling process. All consultations will be noted in your clinical record.
• If a client seriously threatens to harm himself/herself. The Clinician may be obligated to seek hospitalizations for him/her, or to contact family members or others who can help provide protection.

There are some situations where a mental health professional is permitted or required to disclose information without either your consent or authorization:

• If you are involved in a court proceeding and a request is made for information concerning the professional services provided to you, such information is protected by the privacy law. Clinicians cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult your attorney to determine whether a court would be likely to order disclosure of information.
• If a client files a complaint or lawsuit against The Family Counseling Center or the therapist, the clinician may disclose relevant information regarding that client in order to defend themselves.

There are some situations in which clinicians are legally obligated to take actions which are necessary to attempt to protect others from harm and may involve revealing some information about a client’s treatment. These situations are:

• If there is reason to believe that a child who is being treated is an abused child, the law requires that the therapist file a report with the appropriate government agency, usually the Department of Welfare. Once such a report is filed, the therapist may be required to provide additional information.
• If there is reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), the law allows therapist to report this to appropriate authorities. Once such a report is filed, the therapist may be required to provide additional information.
• If a client presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, the therapist may be required to take protective actions such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization.

If such a situation arises, the clinician will make every effort to fully discuss it with you before taking any action and limit the disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important to discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.

Professional Records:
Your professional records includes information regarding your reasons for seeking therapy, a description of the impact your problems may be having on your life, your treatment goals and your progress towards these goals, your medical and social history, your treatment history, any past treatment records received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. Except in unusual circumstances that involve danger to yourself and others or where information has been supplied by others confidentially, or the record makes reference to another person and your clinician believes that access is reasonably likely to cause substantial harm to such other professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, your clinician recommends that you initially review them in their presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, there is a copying fee of $30.00 per request.

It is important to note that in the state of Tennessee your clinician has the right to determine when sending a copy of your records, whether they will include progress notes or a summary of treatment. However, no records will be submitted without a signed release of authorization on file and payment for records is received.

Other Office Policies:
➢ Our office does not allow counselors to accept gifts from clients that are valued over $25. While we appreciate your thoughtfulness, we are prohibited by the canons of our profession not to accept gifts over $25 in value from our clients.
➢ By signing below, you authorize our office to designate an appropriate professional to serve as custodian or your records, and who will assume possession of and responsibility for your treatment records in the event of your counselor’s death.

Client Rights:
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. The rights include that you have the ability to amend your record; requesting restrictions on what information from your clinical record is disclosed to others; and the right to a paper copy of this agreement, the attached notice form, and the privacy policies and procedures.