The process or participating in psychotherapy is one that takes time, patience, and
diligence. Mr. Martin uses an approach that centers around one’s thoughts, feelings, and
actions; how one’s feelings are general indicators of the degree to which one’s needs are
being met; and the degree to which one’s actions are assisting a person in getting his/her
needs met.
I understand that there can be no assurance of outcomes in psychotherapeutic services. I realize that any worthwhile change/growth process involves some discomfort – as I am challenged to leave my “comfort zone” and critically examine my own beliefs and behaviors. I acknowledge that the outcomes of psychotherapy greatly depend on my input and participation, and I agree to participate to the best of my ability. I acknowledge that Mr. Martin may discontinue my therapy and refer me to other provider(s) if I do not show improvement, act in a disruptive or aggressive manner, attend sessions under the influence of drugs/alcohol, and/or fail to actively participate and work on goals I have set forth. I agree to inform Mr. Martin of any significant changes in my physical, emotional, or mental status, or any other data which may have a bearing on my therapy.
Confidentiality: State law and professional ethics require therapists to maintain confidentiality except for the following situations:
1) I (the client, or legal guardian) give Mr. Martin written authorization to release specific information to specific parties. I understand that I may revoke my authorization to release my protected health information at any time by notifying Mr. Martin in writing. No information regarding my therapy, whether written or verbal, will be shared without my written consent – except as described in items 2 through 7 below.
2) If there is suspected abuse or neglect of a child, elder, or dependent adult.
3) A situation in which serious threat to a reasonably well-identified victim is communicated to Mr. Martin.
4) When threat to injure oneself or to attempt/complete suicide is communicated to Mr. Martin.
5) If Mr. Martin believes that a client’s risk of harming oneself or harming someone else is significant and poses a possible safety risk, Mr. Martin may request that other parties become involved in the client’s therapy, including but not limited to client’s family member(s), client’s friends/support system, law enforcement officers. A client’s refusal to allow these safety measures may result in Mr. Martin terminating treatment and referring the client to another provider.
6) The event of a subpoena or the order of a judge to release information.
7) Clients being seen in couple, family, and group work are obligated to respect the confidentiality of others. Mr. Martin will exercise discretion but cannot promise absolute confidentiality when you choose to involve others in your therapy process.
I understand that fees are due when the service is provided. I agree to pay Mr. Martin a the current rate for his services. ($100 per session). I understand that I am responsible for all expenses connected with treatment. Mr. Martin accepts cash, check, debit/credit cards, Pay Pal, and Venmo as payment for services rendered. I understand that if I choose to use a debit or credit card, I will be charged 2.65% of the fee plus 15 cents, and that Pay Pal/Venmo transactions will be charged 2.1% extra to cover the handling fees imposed on Mr. Martin. Checks written for insufficient funds will result in a charge of $50, and your ability to use checks in the future will be forfeited.
I may request Mr. Martin file claims with my insurance provider for individual sessions. I understand that Mr. Martin does not file insurance claims for group sessions. I understand that Mr. Martin does not file claims to Medicare or Medicaid. I understand that my particular insurance policy may not cover outpatient mental health services, and that I will be responsible for all fees that my insurance policy may not cover. I understand that verification of insurance benefits is not a guarantee of payment, and that although Mr. Martin may file insurance claims on my behalf, after Mr. Martin has made reasonable efforts to file claims, if my insurance carrier does not pay the claims in a timely manner, that I will be responsible for the full amount of my fees for services, to be paid directly to Mr. Martin.
I understand that by requesting Mr. Martin to file insurance claims on my behalf, I am authorizing the release of whatever protected health information necessary for the payment of those claims. I understand that insurance claims are made electronically through means that are HIPAA-compliant. I accept the inherent risks to confidentiality in the electronic transmission of my private health information, and I agree to hold Andy Martin, LPC harmless for transmitting necessary information to my insurance carrier. I authorize my insurance carrier to pay Mr. Martin directly, and I agree to forward to Mr. Martin any and all payments that may be made directly to me by my insurance carrier.
I understand that Mr. Martin uses a structured, professional, and confidential practice support service to transition/refer clients in the event that Mr. Martin is unexpectedly incapacitated.
I understand that if I initially enter into a therapeutic relationship with Mr. Martin, I will not
be able to have Mr. Martin later become a formal evaluator for a 3rd party. I will not i nvolve or
engage Mr. Martin in any legal issues or litigation in which I am a party to at any time either
during my counseling or after counseling terminates. This would include any interaction with
the Court system, attorneys, Guardian ad Litems, psychological evaluators, alcohol and drug
evaluators, or any other contact with the legal system. In the event that I wish to have a copy
of my file, and I execute a proper release, Mr. Martin will provide me with a summary of my
treatment record. If I believe it necessary to subpoena Mr. Martin, I understand that I will be
responsible for his Court/witness fees in the amount of $1,000 for one-half (1/2) day to be paid
five (5) days in advance of any court appearance or deposition. Any additional time I spend
over one-half (1/2) day would be billed at the rate of $250 per hour plus travel expenses. I
understand that if I subpoena Mr. Martin, he may elect not to speak with my attorney, and a
subpoena may result in Mr. Martin withdrawing as my counselor. Insurance will not be billed for
these purposes, and fees are to be paid by cash, check, or money order.
Video/Telephonic Services: I understand that Mr. Martin offers video/telephonic services to some
clients on a case-by-case basis. The client understands that a strong Internet/WIFI signal is required
by the client to adequately and properly conduct services virtually. The client agrees to participate in
virtual services from a calm, quiet, and private location that is conducive to the therapeutic process. If
initial attempts to serve the client virtually are unsuccessful due to poor Internet/WIFI signal strength
or environmental distractions, Mr. Martin will offer face-to-face sessions instead. At no time will the
offering of virtual services take precedent over the ethical and proper provision of services offered by
Mr. Martin. The client understands that video sessions are conducted through Doxy.Me, a HIPPA
compliant, secure telehealth program.
Electronic Communication and Social Media: I understand that Mr. Martin will not communicate
with me for any reason by means of Social Media (Facebook, Instagram, Twitter, etc.). I understand
this is to protect my privacy and safety. Scheduling appointments may be done via telephone or text
message – not email. Mr. Martin does not communicate about matters related to the client’s therapy
outside of scheduled appointment times.
Cancellations and Missed Appointments: I understand that I am responsible for all appointment
times that Mr. Martin reserves on my behalf. Should it be necessary for me to cancel an appointment,
I realize I must do so at least 24-hours in advance in order to waive the appointment fee. I
understand that the fee for any and all missed appointments will be due in full before any further
appointments will be scheduled for myself or my dependents. I understand that Mr. Martin will not
bill insurance for missed sessions.
Services will be considered terminated if: 1) my appointment is cancelled and is not rescheduled
within one month, 2) I do not appear for an appointment and do not reschedule, or fail to appear for
the rescheduled appointment. 3) I fail to pay for my services in a timely and mutually agreed upon
manner. Once services are terminated, I understand that Mr. Martin is no longer obligated to provide
therapy services to me.
I understand that I have the right to review my therapy records; however, I agree to have my record review with Mr. Martin present. I understand that there is a $50 fee (not billable to insurance) for me to obtain a summary of my treatment record, and that this fee compensates Mr. Martin for his time and materials. I understand that I have the right to question Mr. Martin regarding any aspect of my therapy at any time.
I understand that if I have a grievance or complaint about my services that I am welcome to bring these concerns to the attention of Mr. Martin. If, after discussing my issue(s) with Mr. Martin, I need to voice further concerns, I acknowledge that I may do so by contacting the office of the Georgia Secretary of State, Licensing Division. http://www.sos.ga.gov/plb/ or call (478) 207-2440.
· I understand that have the right to question Mr. Martin about his professional qualifications and credentials:
Master of Science Degree in Clinical/Counseling Psychology, Valdosta State University, May 2000
Master Addiction Counselor, National Association for Alcoholism and Drug Abuse Counselors (NAADAC)
Licensed Professional Counselor (LPC) - GA Lic No. 4011
Substance Abuse Professional (SAP) as defined by DOT
Member: Licensed Professional Counselor Association of Georgia
Member: Georgia Addiction Counselors Association
· This agreement constitutes the entirety of our professional contract. Any changes must be signed by both parties. You may request a copy of this contract. If you have any questions at all about this agreement, please ask Mr. Martin to help you understand them.
By my signature below, I acknowledge that I am entering into a therapeutic relationship with Andy Martin, LPC, that I have been informed of the policies regarding his services and have read this consent form, and that I agree to all of the arrangements outlined in this form. I fully understand my rights and obligations as a client, and I freely consent to the conditions and arrangements described above.