Informed Consent Form

Welcome to K and G Counseling and Consulting

This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for the purpose of treatment, payment and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Please sign after each section

Psychotherapy/Counseling Services - Consent to Treat

Psychotherapy is a working cooperative relationship between you and your therapist. Each member of this cooperative relationship has certain responsibilities. Your therapist will contribute their knowledge, expertise, and clinical skills. You, as the client, have the responsibility to bring an attitude of collaboration and commitment to the therapeutic process. While there are no guarantees regarding the outcome of the treatment, your commitment may increase the likelihood of a satisfactory experience.

As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following section.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, fear, frustration, loneliness, and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

I understand that I will be taking part in mental health services which are psychological in nature. I hereby give permission for K and G Counseling to provide services.

Consent to Treat – Minor

I understand that my child will be taking part in mental health services which are psychological in nature. I hereby give permission for K & G Counseling to provide services. I understand that consent from both custodial parents is required for treatment services to be provided. I understand that both custodial parents will be provided the opportunity to participate in treatment planning and, when appropriate and recommended by the treating clinician, participate in therapy sessions. I understand that the child is the identified client and billing will be made through insurance coverage on that child for client and/or family sessions. I understand that the decision to meet with me, my attorney, any other party or other attorneys in any custodial or divorce proceeding is at the sole discretion of the clinician.

For children whose parents hold legal joint custody, written permission from both parents to participate in treatment is required by law. I, as JOINT CUSTODIAL PARENT hereby give permission for the above-named child to receive and participate in counseling/mental health services with K and G Counseling.

I understand that there will be a paper copy of this consent form that both custodial parents will need to sign before services can begin.

Fees

The standard fee for hour long sessions is $80. You are responsible for paying at the time of your session unless prior arrangements have been made. K and G Counseling does accept most insurances, but we do not determine the co-pay amount. There may be a delay in knowing the true amount of your amount due or co-pay based on contact from your insurance company and if you have met your deductible. If you have private insurance and choose not to use your policy or do not have insurance, the self-pay rate is $80 per hour.

We reserve the right to suspend therapy if services are not paid for within 30 days. We accept credit cards, checks, and cash as payment. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment. It is not a guarantee that your insurance will cover your treatment. Every insurance policy is written differently, so it is important for you to speak with your insurance regarding your coverage. If your insurance does not cover psychotherapy services or if your coverage lapses, you are responsible for your balance.

In addition to your appointments, it is our practice to charge for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other services which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

We require a card to be kept on file to charge late cancellations and no-show fees. We will contact you prior to running your card.

Professional Records

I, as your therapist, am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure online electronic health record system. I keep brief recordings noting that you were here, your reasons for seeking therapy, the goals and profess we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

Confidentiality

Communication between you and your therapist is confidential. This means that your therapist will not discuss your care orally or in writing with your expressed written consent.

Your therapist has an ethical and legal obligation to break confidentiality under the following circumstances:

• If there is a reason to believe there is an occurrence of a child, elder, or dependent adult abuse or neglect.
• If there is a reason to believe that you have serious intent to harm yourself, someone else, or property by a violent act you may commit.
• If you disclose that you knowingly develop, duplicate, print, download, stream, or access through any electronic or digital media exchanges, a film, photograph, or video in which a child is engaged in an act of obscene sexual conduct.
• If you introduce your emotional condition into a legal proceeding.
• If there is a court order for the release of your records.

Availability and After Hours Emergencies

Therapists check for voice messages during normal business hours. Messages left outside of normal hours of operation will be picked up the next business day. If you have an emergency that needs immediate attention you may need to seek assistance at the nearest emergency services department.

Contacting Me

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voicemail or via text message and your contact will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, contact your local hospital emergency room, or call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences.

Child Care Release

We do not provide childcare and it is not responsible for children and adolescents left unsupervised in the waiting room. Minors must be picked up following their appointments on time. If you must leave your child in the waiting room during a session, it is your responsibility to provide appropriate supervision for that child. Children under the age of 13 may not be left without supervision in the waiting room.

Additional Rights and Responsibilities

In addition to your right to confidentiality, you have the right to end your counseling at any time, for whatever reason and without any obligation, with the exception of payment of fees for services already provided. You have the right to question any aspect of your treatment with your therapist.

You also have the right to expect that your therapist will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you.

If you are unhappy with what is happening in therapy, I hope that you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist.

You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, or national origin. You have the right to ask questions about any aspects of therapy and about my specific training and experience.

We reserve the right to discontinue counseling at any time including, but not limited to, a violation by you of this Consent for Treatment, a change or reevaluation of your therapeutic needs, our ability to address those needs, or other circumstances that lead us to conclude in its sole and absolute discretion that your counseling needs would be better served at another counseling facility. Under such circumstances, we will suggest an appropriate therapist or counseling agency.

Your signature below indicated that you have read and understand this information and have received a copy of this consent form and give permission to us to provide counseling services and that this contract is binding for all future sessions you may have with this entity.

If you are signing this as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form.