115 E Montgomery Street

Gaffney, SC

29340

Phone: 864-597-9493

**Please star the name of the client being provided services

Telephone Numbers for client and/or guardian:

I give my permission for this person to be contacted by Outside of the Box Therapy in case of an

Please be aware that any record copies, preparation, travel time and testimony fees are not billable to insurance and are payable upfront prior to going to court.

Health History (please check all that apply):

Medication allergies (if checked, please describe):

Medical Health Insurance Information:

**Please note if you have Medicaid as a secondary insurance you must provide us with the primary insurance information. Failure to do this will result in a denial from Medicaid and fees out of pocket. ***

I have been given the opportunity to ask any questions I might have regarding this information.

New Client Information Policy Statement and Informed Consent for Treatment:

 

Please read the following information and sign below. If you have any questions, I would be happy to review

The counselors at Outside of the Box Therapy are all Licensed by the professional boards for their profession and have several years experience working with clients in a variety of settings. We are serious about following the rules of our licensing board and abiding by our Code of Ethics, both of which are in place to protect you. Some of us have additional trainings in certain area and certifications in specialized areas. We consider your unique situation and set of needs when we work with you to assign a counselor to you. Since we are all different and may not be effective for everyone, if you are unsatisfied with one counselor you can make the request to switch to another counselor in the practice.

We truly value the therapeutic relationship between the client and counselor and believe it is the key ingredient to sparking change and healing in the lives of our clients. Our areas of training are the systemic treatment of individuals, couples and families. This approach takes into consideration all immediate family members in a family therapy session. We believe in a wellness model as apposed to a medical model. While a medical diagnosis may be required for insurance purposes, it is not our intention to determine what is "wrong" with clients but rather to focus on what is right and already working for them in their life. We believein empowering clients and using a wide variety of techniques and interventions to make meaning of their experiences and beable tomove forward on their journey. Together, we will decide which family members (if any) need to be included in therapy. Various goals will be established together with you at the outset of therapy. Please note, we cannot ensure confidentiality of any participants you choose to bring into sessions.

Therapy naturally involves activities such as identifying emotions and revealing secrets. There may be risks associated with your disclosures to other family members, or other family member's disclosures during the course of therapy, as well as exploration of issues. Decisions to disclose will be made by you except where mandated by law. It is expected that some uneasiness or painful emotions may occur as you are involved in therapy. Discussing painful issues will naturally create discomfort. While this may happen, keeping consistent appointments and a commitment to yourself and your healing is best. It is our promise to always see you as a valuable, worthwhile human being and always our desire is to offer guidance and tools necessary for you to reach

your counseling goals. Your participation in therapy is essential toward helping you address your concerns. The Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists and Psychoeducational Specialists requires that all clients be informed that all forms of dual relationships, such as business ventures and sexual intimacy, are prohibited.

Please be aware that there is a higher incidence of divorce if only one partner in a relationship is involved in therapy. It is also important that you understand that there is no guarantee all of your concerns/ issues/problems, etc. will be successfully resolved. I cannot guarantee outcomes. The outcomes may vary from your expectations. You may discontinue participation in therapy at any time. However, before you do, we encourage you to share your concerns if you are dissatisfied with the course of therapy. Outside of the Box is a teaching center and, as such, students may be present in sessions. You have the right to refuse their participation in your treatment and will be asked your consent prior to their inclusion.

 

The nature of the counselor-client relationship is professional. Our contact will be limited to our scheduled sessions and brief calls/texts to schedule future appointments. It is always best to share information in session where you can have our full attention and it can be documented as needed. Long texts, voicemails and other forms of communication that are not face-to-face or in session are discouraged and not in your best interest for quality treatment. Social invitations and offers of that nature will be politely turned down in honor of our Code of Ethics associated with our licensing board. However, if you see us and would like to greet us, we are happy to say hello. Anything you share in session is held in confidence and will not knowingly be shared with another person without your written consent. Our center is also collaborative so we often case consult among ourselves. If you have a connection with a current therapist of the practice outside of counseling, please advise your therapist sothathe/she does not bring your information to those case consultations.

I understand the following services may be available:

*Behavioral assistance for common adolescent concerns *Diagnostic Assessment (DA) Services which identifies
the client’s needs, concerns, strengths and deficits and allows the beneficiary and his or her family to make
informed decisions about the treatment. * Service Plan/Plan of Care Development which is a face-to-face
interaction between the client and his approved family members and a qualified clinical professional, or a team of
professionals, to develop a plan of care based on the assessed needs. * Therapy Services (individual, family, and
group) which are planned face-to-face interventions intended to help the beneficiary achieve and maintain stability

* Medication Management which is to educate the client about his or her medication, to determine any
physiological and/or psychological effects of medication(s) on the client and to monitor the compliance with his or
her medication regime * Crisis Management is face-to-face or telephonic short-term service is to assist a client who
is experiencing a marked deterioration of functioning related to a specific precipitant, in restoring his or her level
of functioning.

When utilizing faxes, electronic communication devises and web-based management systems, there is always a level of vulnerability that may not be preventable despite all safeguards that have been put into place.

Exceptions to Confidentiality:

Although shared personal information is confidential there are exceptions to these confidences such as: (1) Suicidal threats or attempts. (2) To prevent a clear and immediate danger to another person. (3) Suspected child abuse or neglect. (4) Suspected abuse or neglect of a vulnerable adult. (5) If it is determined that you are in need of hospitalization. (6) Or otherwise mandated or allowed by law or ethical codes for which we am responsible. We are subject to subpoena. Please note that, in the cases of minor children, both parents will be informed of treatment goals and receive summaries of services.

Our practice is dedicated to maintaining the privacy of your personal health information as part of providing of professional care. We are required by law to keep your information private. Your therapist will give you a copy the Health Insurance Portability and Accountability Act of 1996 (HIPPA) which will explain your rights as a therapy client. If you have any questions about this notice or our privacy policies, please contact our office at 864- 597-9493.

In order to stay in compliance with state law, we require a copy of custodial agreements in the event that both biological parents do not reside together in the home or the signature of both parents on the intake form within two visits or we will be unable to provide services for minor children. The other parent will be notified that the child has been signed up for services. Depending on your court documentation, this may hinder services. We realize that there are situations where an external agency or outside party may have custodial rights. In those situations, we will need approval of that agency or party to provide services.

Appointments are usually scheduled with the therapist, or the main office (864-597-9493 Appointments are50minuteseach,unlessotherwisearrangedwithyourInanefforttoprovidehigh therapist. approximately quality service, we will try to provide the option of set appointment times. These recurring appointment times would remain consistent throughout service. However, due to the impact to the therapist's schedule, failureto

consistently attend those appointments will result in being removed from a rotating schedule after the second missed appointment without prior notice and seen as the therapist schedule allows.

** Recurring appointment times, once set, will have another form for signature Due to insurance guidelines, as well as ensuring that our therapists can provide services to all, late arrival to appointments (15 minutes or more) may result in your therapist being unable to see you during that time period. We will attempt to schedule you in as quickly as possible. If you fear that you may be late, please attempttonotify the office.

Therapy centers differ in many respects from medical centers. Unlike physicians, dentists and other professionalswhooperateonmoreflexibleandinexactschedules,therapistscommitaspecifictimeperiodfor each person. Thus, it is important that you appreciate the fact that a block of time has been set aside just for you. We understand that conflicts can occur after an appointment has been scheduled and, should that happen, please

Confidentiality is the foundation for effective counseling and therapy. Developing trust and confidence in those
who listen and help is paramount to successful therapeutic experience. Shared personal information is strictly
confidential and will not be revealed unless you, or a parent, in the case of a minor (less than 18 years old), give
specific written authorization to release information. The office will be discreet if they must contact you at your
home or office. If you do not wish to be contacted at home or the office, please let me or my office staff know so it
can be recorded in your records. Please let the office know how you wish to be contacted.

When utilizing faxes, electronic communication devises and web-based management systems, there is always a
level of vulnerability that may not be preventable despite all safeguards that have been put into place.

Although shared personal information is confidential there are exceptions to these confidences such as:

(1) Suicidal threats or attempts.

(2) To prevent a clear and immediate danger to another person.

(3) Suspected child abuse or
neglect.

(4) Suspected abuse or neglect of a vulnerable adult.

(5) If it is determined that you are in need of
hospitalization.

(6) Or otherwise mandated or allowed by law or ethical codes for which we am responsible. We
are subject to subpoena. Please note that, in the cases of minor children, both parents will be informed of treatment
goals and receive summaries of services.

Our practice is dedicated to maintaining the privacy of your personal health information as part of providing
professional care. We are required by law to keep your information private. Your therapist will give you a copy of
the Health Insurance Portability and Accountability Act of 1996 (HIPPA) which will explain your rights as a
therapy client. If you have any questions about this notice or our privacy policies, please contact our office at 864-
597-9493

In order to stay in compliance with state law, we require a copy of custodial agreements in the event that both
biological parents do not reside together in the home or the signature of both parents on the intake form within two
visits or we will be unable to provide services for minor children. The other parent will be notified that the child
has been signed up for services. Depending on your court documentation, this may hinder services. We realize that
there are situations where an external agency or outside party may have custodial rights. In those situations, we
will need approval of that agency or party to provide services.

Appointments are usually scheduled with the therapist, or the main office (864-597-9493). Appointments
are approximately 50 minutes each, unless otherwise arranged with your therapist. In an effort to provide high
quality service, we will try to provide the option of set appointment times. These recurring appointment times
would remain consistent throughout service. However, due to the impact to the therapist’s schedule, failure to
consistently attend those appointments will result in being removed from a rotating schedule after the second
missed appointment without prior notice and seen as the therapist schedule allows.

** Recurring appointment times, once set, will have another form for signature
Due to insurance guidelines, as well as ensuring that our therapists can provide services to all, late arrival to
appointments (15 minutes or more) may result in your therapist being unable to see you during that time period.
We will attempt to schedule you in as quickly as possible. If you fear that you may be late, please attempt to notify
the office.

Therapy centers differ in many respects from medical centers. Unlike physicians, dentists and other
professionals who operate on more flexible and inexact schedules, therapists commit a specific time period for
each person. Thus, it is important that you appreciate the fact that a block of time has been set aside just for you.
We understand that conflicts can occur after an appointment has been scheduled and, should that happen, please
notify the office 24 hours in advice if you must cancel or reschedule. Although you can also notify this via the text
reminder call, we ask that you do not call or text that number back as it will not reach our office. Although we give
grace the first time you fail to show up or notify the office, after that a charge of $60 will be applied to your
account and must be paid by the next session unless a payment arrangement has been established with your
therapist.

**Three no shows, no contacts may result in your therapist releasing you from service with them.

The private pay fee for initial intake appointments or for sessions ranges depending on the fees of the
therapist. The diversity of training and background account for this difference. We also have low cost options via
telehealth with students in the MACC program at Erskine Theological Seminary, as they are supervised by our
practice.
We do accept most insurances for payment of counseling services. It is your responsibility to obtain
authorization from your insurance company for services. Your co-pay is due at the time of the appointment.
Please be sure that you have met your deductible. If you have not met your deductible you will be responsible
for the fee for the session until the deductible is met. For people who do not have insurance, appointments are
based on a sliding scale fee based on income and therapist availability. If there is a hardship, please consider how
much you can afford and discuss this with your therapist. You may pay by cash, or credit card. If you are unable
to pay for a session, please notify the therapist before the session. At times, this becomes a therapeutic issue
and appointments need to be rescheduled until you are able to take responsibility for your fee. All billing,
insurance and fees are handled through our Office Manager who will send you a bill for services. If you do not
receive a bill, or dispute a bill, please contact our Office Manager, as she will help you with any billing issues and
develop a payment plan with you. Please know that services may be suspended after two unpaid services. Thank
you.

Outside of the Box Therapy does not maintain an electronic health record, though they do compile notes and
schedules on Theranest. For clients with existing records or records from other providers, those will be kept for
outside communications. Since paper files are maintained, therapists will be happy to provide you with a copy of
the treatment plan and a summary of services free of charge. Any additional information will incur a charge that
must be paid prior to release

Your signature on the informed consent confirms that you understand and agree with the tools, instruments,
questionnaire, psychological batteries or other related materials used for the evaluations are copyrighted by the
corresponding publishing agency and are used for the purposes of this evaluation. In addition, you understand and
agree that you will not request these copyrighted materials and will defer to the mental health evaluations report or
summary.

I have been educated about confidentiality as it pertains to electronic communications. Although your therapist will take significant steps to ensure confidentiality and privacy of online communication(s), these actions, in whole or in part, cannot guarantee the security of internet transmissions. I permanently agree to release and indemnify Outside of the Box Therapy and its therapists from all suits, claims and other actions origination from psychotherapy.

I do/do not authorize my counselor to leave voice mail messages regarding appointment times, respond to my texts or participate with me in virtual therapy sessions.

The following statements provide your legal consent to and financial responsibility for the counseling services to thethe the minor.Theseand astatementsareimportantchild,parent/guardian/conservator,counselor. toprotect Please carefully review this information and sign where indicated.

Outside of the Box Therapy is committed to confidentiality and privileged communication with all clients. There are however, several exceptions. According to South Carolina law, any evidence of child abuse/neglect must be reported to the authorities. If any individual intends to take harmful, dangerous or criminal action against another individual, or against himself/herself, it may be the counselor's duty to report such action or intent.Forclientsover the age of 12, we will also ask for their signature on the Adolescent Informed Consent so that both parent and child are aware of the 'grey areas'.

I acknowledge that I have read the above Duty to Warn Notice and understand the counselor's responsibility to take action where necessary.

It is required the South Carolina Licensing boards that we keep a copy of legal paperwork on file stating who has the authority for making mental health decisions for a minor. It will be necessary to provide this to the counselor BEFORE your child's second session. This document, along with other information, will be kept confidentially within the client's paper record.

Research tells us that the children will do best with the involvement of BOTH parents. This may mean coordination between therapists with one working directly, and individually with the client, and another working with the parents or in family sessions. This is to provide your child a 'safe place/person' to express their thoughts and feelings while working with the larger family unit. In order for your child's therapy to be effective,itis important for you to understand how treatment works and agree to the following conditions.

1) Our priority is your child's emotional and behavioral health. Treatment will focus on your child, any adjustments to changing family conditions, and his/her achievement of therapy goals.

2) Unless specified for reunification therapy, or coparenting therapy, the therapist will not take sides in any disputes between you and the other parent. If you are involved in legal proceedings, please notify the office as soon as possible so we can determine how this involvement may affect our work together.

3) The practice's staff will not be exposed to domestic issues or disagreements over the phone or in the office. Additionally, please make decisions regarding appointments and/or any office procedures prior to visiting the practice.

4) Depending on the needs of your child, you may seek additional services from Outside of the Box. Please understand that the therapists will work together but it typically means the involvement of another so that the integrity of therapy can be ensured.

5) We will attempt to involve both parents in your child's treatment as necessary and in accordance with professional judgement, except in cases of abuse or serious impairment on the part of one or both parents, or when the other parent would be detrimental to the child's mental health or treatment. Both parents will have access to the child's treatment plan, as well as a summary of visits upon request. If needed, a private meeting with the counselor can be arranged to discuss treatment concerns.

6)Only in situations where there is a confirmed, documented Court Order will a parent be denied visits to the office.

7) Please protect your child from conflict related to separation, divorce, or custody issues. Try not to argue in front of your child or involve your child in adult conflicts. Whenever possible, support your child's relationship with the other parent.

8) It is the parents' responsibility to communicate with each other about their child's care, office visit dates, and any other relevant information. We will not communicate your child's session information to each parent separately, or contact a non-attending parent following visits. We will also not contact the other parent for consent regarding appointments schedule, or restrict either parent's involvement in their child's care unless authorized by the law.

9) Any information that is disclosed may be included in your child's treatment record, which may be accessible by the other parent. Only in situations where there is a confirmed, documented Court Order will a parent be denied access to a child's treatment summary.

10) Telephone, face-to-face, video, e-mail, or written communication from either parent may be shared as is clinically appropriate at the discretion of the therapist, with the other parent, or with the child. These communications become part of your child's treatment record.

11)If there is not a Court Order preventing visits, either parent can sign an ROI form that authorizes any named individuals (grandparents, nanny, etc) to bring the child to our practice, be present in the lobby during visits, and consent to any treatment during that visit.

12) We will report any safety concerns. Although your child's treatment is confidential and privileged, if there is a concern for your child's safety, a report will be made to the authorities. If the actions of either parent

are compromising client care, we reserve the right to discharge the family from the practice.

Please provide the name and contact information for both parties so that that we are made aware of those who may seek information about counseling services. Unless parents have sole medical decision making responsibility in the court paperwork, we would need the consent of both parents before we undergo therapeutic services

Statement of responsibility and grant of permission for counseling

I am legally responsible for the child named above and grant permission for Outside of the Box Therapy to conduct counseling with this child. Upon request, I will provide any necessary documentation, such as divorce degrees, court orders, temporary orders, restraining orders, etc. I understand that if I fail to disclose any legal proceedings or orders prior to and during counseling, my child's counseling services may be terminated.

I accept responsibility for timely payment of all fees due to Outside of the Box Therapy for services provided to this child. If the case goes to court, I understand that I accept full responsibility of payment to Outside of the Box Therapy for any court related costs, whether or not I initiate any court proceedings.

I have read this information and have had an opportunity to ask questions. My signature below indicates that I agree to all of the above terms and conditions.