Welcome to Living Water Counseling. Please take a few minutes to read through this informed consent form to understand more about counseling and get to learn more about the solutions that can help you address your concerns to get you back on track.

COUNSELING. Counseling is a process carried on in a one-on-one professional relationship between a licensed therapist and their client . The therapist's role is assisting the client who is seeking to learn more about themselves; support them in exploring difficulties; and aiding them to better understand and relate to themselves and others.  The desired outcome is the client reaching client-defined positive goals to improve functioning, enjoyment and fulfillment in life.

CONFIDENTIALITY. We highly respect the privacy and confidentiality of each of our clients. We likewise believe that for counseling to be effective and successful, we must make our clients feel secure about the information that they disclose with us. We keep our clients' records in a secure manner and we do not allow it to be accessed or to be shared with anyone else unless with the written consent of our client who owns the information, both clinical information and personal. If records receive no update within a period of 7 years, we purge the records for privacy protection.

However, we would like to let you know that privacy has its limitations in law and we would like to inform you of the circumstances where we may share information to a 3rd party without your consent:

• Acts of sexual abuse or misconduct
• Criminal acts
• Acts of abuse towards others such as neglect towards children, disabled, or the elderly
• Acts that the therapist believe may cause harm to the client himself or to others
• Compelling legal orders by the court, but nonetheless we will inform the client immediately prior to compliance with the order.
• In case the client is below legal age, we may disclose information to parents or legal guardians.

SESSION APPOINTMENTS. Each session takes approximately 50-60 minutes. Counseling sessions are taken as reservations and occur by appointment. In case the client will not be able to attend the scheduled appointment, he/she should call 24-hours prior appointment or he/she will be charged 100% of the session fee.

FEES. Fees are charged on a per session basis. We may directly bill your insurance company by informing us of the details. If you are planning to pay, here are our schedule of fees (sliding scale fees are available due to hardship):

• Sessions:  Intial Intake ($150)  Counseling Sessions ($130)
• Couples Counseling ($140)
• Family Counseling ($150)

Summary reports per request:  $200.00

File Requests:  $150.00

Living Water Counseling uses external providers to enhance services including the Upheal platform. Upheal empowers counselors to concentrate on their services by offering automated notes and analytics for client conversations. As a part of this process, Upheal handles protected health information for counselors, adhering to HIPAA regulations as a Business Associate.
 
Living Water Counseling has signed a Business Associate Agreement (BAA) to protect data that is shared with Upheal. Under the BAA, Upheal adheres to regulations such as the HIPAA Security Rule and Privacy Rule. This ensures that electronic health information (ePHI) is safeguarded through appropriate administrative, physical, and technical measures, ensuring its confidentiality, integrity, and security. You can learn more about Upheal and its privacy practices at www.upheal.io/privacy.

CONSENT

I understand that this consent is purely voluntary. I have had the opportunity to discuss any concerns with regard to the services and treatment and by which all questions were answered accordingly and to my satisfaction. 

I understand that I can withdraw anytime from the therapy by informing my therapist. By signing below, I expressly give my consent to the treatment and therapy sessions with the therapist.