New Client Paperwork

Courtney Miller, M.A., LPC

PROFESSIONAL DISCLOSURE STATEMENT

QUALIFICATIONS: I am a Licensed Professional Counselor in the state of Texas. I earned my Bachelor’s degree in 2001 from The University of Texas at Austin in Engineering Route to Business (Electrical Engineering and Marketing concentrations) and my Master’s degree in Clinical/Counseling Psychology from La Salle University in 2006.

EXPERIENCE: During my years of experience, I have worked with every age group in a variety of settings – crisis intervention, community mental health, partial hospitalization, intensive outpatient, and inpatient. I currently work with older adolescents, adults, families, and couples dealing with a wide variety of emotional, behavioral, and relational issues.

NATURE OF COUNSELING: During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, systems/family, developmental (adult, child, family), humanistic or psycho-educational. The aim of counseling is to reach specific goals for individual and relational growth, which are mutually agreed upon by both the client and the counselor. I believe that my fundamental role as a counselor is to provide you with a safe place to be truly heard, to help you gain insight into yourself, and to teach you new strategies to improve your life. This will be achieved through a combination of exercises, homework, readings, and the therapeutic relationship.

INFORMED CONSENT

COUNSELING RELATIONSHIP: During the time that we work together, we will meet at a mutually agreed upon frequency for approximately 30-minute, 60-minute, or 90-minute sessions. It is important to remember that our relationship is strictly professional, and not social. Our policy and that of the professional counselor ethics prohibit the receipt of gifts valued more than $50 to counselors by clients.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Partcipation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. As stated, there are benefits and risks in all mental health counseling. Common risks include the following: presenting symptoms/concerns do not improve; or, they worsen. Possibly, new symptoms/concerns might arise during the therapeutic process. I will check with you regularly as to your assessment of the benefits of counseling. Please share with me any concerns you have on an on-going basis.

CLIENT RIGHTS AND RESPONSIBITIES: Some clients need only a few counseling sessions to achieve their goals; others may require months or even years of counseling. As a client, you are in complete control and may end our counseling relationship at any time, though I do ask that you participate in a termination session. You also have the right to refuse or discuss modification of any of my counseling techniques or suggestions that you believe might be harmful. You agree to come to counseling free from the influence of drugs, including alcohol. I assure you that my services will be rendered in a professional manner consistent with accepted legal and ethical standards. If at any time, for any reason, you are dissatisfied with my services, please let me know. If I am unable to resolve your concerns, you may contact:

Texas Behavioral Health Executive Council - Licensed Professional Counselors
333 Guadalupe St., Suite 3-900 Austin, TX 78701
(512) 305-7700

FEES: Services will be provided for a fee of $85 per 30-minute session, $165 per 60-minute session and $225 per 90-minute session. The fee for each session will be due at the conclusion of each session. I use a HIPAA-compliant application, Ivy Pay, for all client payments. After session, you will receive a text message from Ivy Pay inviting you to put a card on file. Unless I am otherwise notified, the card you put on file will be charged for all subsequent sessions. Courtney Miller Psychotherapy does not file for reimbursement from health insurance companies, but can provide you with documentation to submit to your insurance company for reimbursement.

CLIENT NO-SHOW/LATE CANCELLATION: When you have an appointment, I reserve that time for you and make it unavailable to any other client. If you cancel or reschedule an appointment, it is very rare that I am able to fill that slot with another client when less than 3 to 4 days’ notice is given. Because Courtney Miller Psychotherapy is a small private practice, the cancellation policy is integral to business. It is understood that you may need to reschedule in the event of an emergency. However, for anything other than an emergency, please provide me with at least 48 hours notice in order to avoid paying for the full session fee. Appointments are a purchase of “time” and clients who fail to show up for an appointment, cancel, or reschedule with insufficient notice will be charged accordingly. I am tremendously grateful for your understanding regarding this important issue.

ACCESS TO YOUR MEDICAL INFORMATION/CONFIDENTIALITY: The law requires me to protect the privacy of your health informaOon. This means that I will not use or let other people see your health information without your permission except in the ways I tell you in this notice. I will safeguard your health information and keep it private. This protection applies to all health information I have about you, no matter when or where you sought services. When you are in my office, I will not allow any unauthorized person to interview, photograph or record you without your written permission. I will not tell anyone if you sought, are receiving, or have ever received services from me unless the law allows me to disclose that information. If I see you in public outside of my office, I will not approach you or act as if I recognize you. It is important for you to know that there are some situations in which I am required to break confidentiality:

1) If I determine you are a danger to yourself or someone else;

2) You disclose abuse, neglect, or exploitation of a child, elderly, or disabled person;

3) You disclose sexual contact with another mental health professional or clergy;

4) I am ordered by the court to disclose information;

5) You direct me to release your records; or

6) I am otherwise required by law to disclose information

I will ask you for your written permission to use or disclose your health information. If you give your permission to use or disclose your health information, you may take it back (revoke it) at any time. If you revoke your permission, I will not be liable for using or disclosing your health information before I knew you revoked your permission. To revoke your permission, send a written statement signed by you to the office address where you gave your permission, providing the date and purpose of the permission and stating that you want to revoke it.

Confidentiality Statement Specifically for Couples

Relationship therapy works best when the focus of my work is on your relationship. When working with you, it is expressly understood that my patient is both your relationship and each of you as individuals. This document describes my policies on confidentiality when I am working with couples. In my experience, it is best when these issues are talked about and understood from the start of treatment.

In individual therapy, any information obtained by having contact with a client is confidential and cannot be shared with anyone without the specific consent or authorization of the client, or except by law. However, in couple therapy, the psychotherapist may meet individually with one spouse, and the therapist will be influenced by this individual contact when meeting with the other spouse. There are also many instances when the therapist may use knowledge gained from individual sessions with the other spouse. An example is when the therapist makes a statement such as: “When I speak to your wife/ partner, I get the impression that she is interested in making your relationship better for both of you”. Therefore, in this way a couple therapist cannot promise complete confidentiality to each individual in joint therapy.

On the other hand, individuals may have some feelings, thoughts, or actions that they would like to keep confidential. While I will not agree to keep any secrets learned from individuals, I believe in respecting these confidences or sensitive topics if possible. Therefore, any information provided to me, regardless of whether the partner/spouse was present, may be either withheld or disclosed to the other party at my discretion. Additionally, both parties must understand and agree that in order to keep proper records, I may make written record of any information provided by either party or any observation made of either party’s behavior.

Another kind of exception to confidentiality occurs when keeping an individual’s confidence places me in a position of behaving dishonestly. An example of this kind of situation would be a husband who tells me in private about plans to leave his wife or to continue an affair, but wants to continue the couple’s therapy as if he planned to stay in the marriage and was being honest. I would need to work with him to help him to tell his wife, since we could not continue therapy if we were deceiving her. The time frame for maintaining confidentiality in this work is at my discretion.

To summarize, my rules for confidentiality, with couples specifically, are as follows:

1. I will maintain the same standards of confidentiality and privacy as in individual therapy when I contact anyone outside the couple.

2. I am willing to keep confidences as long as they do not conflict with the law, do not place me in a position of being deceitful with the other spouse, or I do not think they are inappropriate therapeutically. However, it must also be understood that I cannot guarantee the maintenance of confidences between spouses, and there is always a small but real possibility that a confidence will be accidentally revealed to the other spouse. There are also occasions when I may advise that a confidence be revealed or I may set a time frame in which one member must voluntarily reveal information we have talked about individually. I cannot guarantee that others will always agree with my choices.

3. In addition, I would like to explain that my commitment is to the well-being of all individuals in the marriage. When both partners wish to work on their relationship, we will make a commitment to the relationship as long as it is the choice of both partners. It is my position that only the partners can make the decision about keeping a relationship together or separating, and realistically, divorce or separation may be a possibility. I must also be free to discuss the possibility of divorce or separation with either partner when I believe that this discussion is appropriate or necessary.

4. In regards to the Clinical Record involving a couple or family members, it is important to know that anyone who is a client and attended a session(s) jointly may have access to a complete copy of the file. That means that in my chart notes, information about each person involved in the therapy may be available to the other without further consent. In making this agreement, it is recognized that either party might further disclose information obtained from this file and I have no control over such re-release of information. If an “outside” third party wishes to access the file, signatures of both partners/spouses will be required in order to release the requested information. Certain exceptions to these confidentiality and access provisions may be required by law.

CUSTODY AND CONTROL OF RECORDS: All of our communication becomes part of the clinical record. Records are the property of Courtney Miller Psychotherapy. All client records are disposed of 7 years after the file is closed; this applies to both adult and minor clients. In the event of my death or incapacity, or the termination of my counseling practice, the custody and control of your records will be given to Gina Watson, LMFT.

COURT PROCEEDINGS/SUBPOENA OF RECORDS: It is understood that the purpose of marital/couple therapy is for the amelioration of distress within a relationship. Therefore, if both partners request my services as a licensed professional counselor, they are expected not to use information given to me during the therapy process against the other party in a judicial sedng of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena my testimony or my records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case.

TERMINATION and REFERRALS: Ethically, I am required to always assess the benefit of counseling to you. If at any point during psychotherapy I assess that I am not effective in helping you reach the therapeutic goals, or that you are non-compliant to the process, I am obligated to discuss this with you and, if appropriate, to terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it, and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you with referrals, and with your written consent, I will provide him/her with the essential information needed. You have the right to terminate therapy at any time. I reserve the right to refuse service to anyone without reason, provided that a referral to an appropriate treatment provider is made at the time of refusal of services.

ELECTRONIC COMMUNICATION (i.e., text, email):

Information sent over computer servers is generally not secure and we care deeply about confidentiality. We advise that communications which are confidential in nature, or intended to remain private, should not be sent electronically. This includes e-mail and text. Consider that receiving e-mails or text messages from a therapist could alert friends, family or co-workers to the fact that you are receiving services from a mental health professional. You should carefully assess any potential risk to your privacy.

Although we treat all communications with the full confidence which the law provides, the fact is that electronic communications are, by their nature, not secure and could potentially be accessed or intercepted by a third-party. In addition, there is always a possibility that email will not be received because of spam blockers, a worm or virus, system malfunctions, or other cause. It is important that your communication is received and that you know it was received. We strongly recommend using a private e-mail address rather than a work e-mail address. If your employer has access to your e-mails, they may discover that you are a client of Courtney Miller Psychotherapy. We do utilize e-mail and text message to communicate scheduling and appointment reminders and occasionally may use e-mail for homework assignments completed outside of our offices between sessions. This is always voluntary, and you may opt out at any time. By signing below, you are acknowledging that you understand risks to your privacy when communicating via e-mail or text to your therapist. I have been informed of the risks to my privacy and consent to receive electronic communication from therapists of Courtney Miller Psychotherapy.

CONTACTING ME: You may have my cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email and text messaging are not secure mediums in terms of privacy and confidentiality, so my policy regarding electronic communication and cell phone use includes the following:

• I do not provide therapy/counseling via text messaging.
• Text messaging will be used for administrative tasks only (as defined above).
• I may not acknowledge text messages that are not administrative.
• If I leave for an extended period of time you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during my absence.

EMERGENCIES

• If you have an emergency do not contact me via my cell phone – this is not monitored regularly.
• If you have an emergency do not contact me via email – this is not monitored regularly.
• If you have an emergency go to the emergency room nearest you or call 911.

ACKNOWLEDGMENT AND CONSENT: By your signature below, you are indicating that you have read and understood this statement, or that any questions you had about this statement were answered to your satisfaction, and that you were furnished a copy of this statement. By my signature, I verify the accuracy of this statement and acknowledge my commitment to conform to its specifications.