Client Informed Consent Form

Anchored in Hope Counseling Services employs licensed professional counselors who have completed a master’s degree program at an accredited university and necessary supervision requirements for licensure in the state of Pennsylvania. We are committed to offering the highest quality mental health counseling services to assist clients in developing skills to live their best life. Our counselors use effective evidence-based clinical treatments along with a caring, compassionate and non-judgmental therapeutic alliance to address our clients' needs and concerns. 

Counseling is an intricate process that offers benefits and can also pose risks. There are no guarantees about what you will experience, but your counselor will be able to support you through the process. Counseling involves a significant commitment and you should feel comfortable with the therapeutic relationship. The therapeutic relationship is an essential component for successful treatment. You and your counselor have a professional relationship existing exclusively for treatment. Your counselor can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. We can only counsel within the scope of our practice. If it is determined that a client would be better served by a different provider, then appropriate referrals will be made.

Please read each of the following sections and initial to identify understanding and acceptance of the information provided:

CONFIDENTIALITY
One of the most important rights of yours as a client is confidentiality. Information revealed by you will be kept strictly confidential and will not be revealed to any other person or agency without your written permission, with the following exceptions (for more information on HIPAA compliance, see Privacy Practices handout):
 Harm to Self or Others: If there is reason to believe you are in danger of physically harming yourself or another person, the counselor may seek your admission to a hospital and/or contact a family member or another person in order to ensure safety of yourself and/or others.
 Abuse of Child or Dependent Adult: If there is reason to believe a child or dependent adult is being abused, the counselor is legally obligated to report the situation to the authority.
 Consultations with Other Professionals: It is often helpful to consult with other professionals about clinical work in order to provide the best care. Client identity is often hidden and the other professionals also legally bound to maintain confidentiality.
 Under Eighteen: If you are under eighteen years old, please be aware that while the specific content of our communication will remain confidential, your legal guardian(s) have the right to receive general information on how your treatment is proceeding.

COMMUNICATION/EMERGENCY ISSUES
Communication outside of therapy appointments is often necessary to address various client concerns. Due to the nature of the small practice, it is not guaranteed that phone calls will be answered at the time of contact. However, counselors will make every effort to respond to client communication within 48 hours. If you require assistance during emergency situations or outside of office hours, please take the following steps to secure safety: call Clearfield/Jefferson Mobile Crisis: 1-800-341-5040; go to local emergency room (face-to-face evaluation available at Penn Highlands Dubois); or call 911.

ATTENDANCE POLICY/DISCHARGE
Consistent attendance is essential to therapeutic progress. Clients are scheduled a 50 minute counseling session on a regular basis with frequency agreed upon with your counselor. All clients must be seen at least one time every 3 months unless the provider agrees to other arrangements. We request a 24 hour notice for session cancellations. Clients are allowed one “free” missed appointment, but subsequent no shows will be automatically charged $25 to the client’s account. If you fail to show for three appointments in a 12-month period and/or if you fail to reschedule a missed appointment within 30 days, you will be considered to have terminated treatment and will be discharged.

INVOLVEMENT IN LEGAL COURT CASES
Our counselors do not specialize in assessment of bonding/relationships, disabilities/ability to hold employment, or fully evaluate mental stability/instability as related to legal or criminal issues. This practice will limit the feedback provided to any legal entity due to the scope of practice, expertise/training, preservation of the therapeutic relationship, and confidentiality.

If documents are requested, it is possible that we may be willing to provide the following information: a letter of attendance and compliance with treatment, current diagnosis, and most recently updated treatment plan. However, due to the contribution of time given by the counselor to provide such documentation, a fee will be set and agreed upon at the time of request. If the counselor is subpoenaed for attendance at court in any type of legal case, a fee of $250 per day will be requested by the client prior to the date of court.

FEES AND INSURANCE
We are contracted by many major insurance companies and will submit claims to these participating companies as a courtesy to you. Services are provided with the understanding that you, the client, are ultimately responsible for the cost of the services completed. All copays, deductibles, and self-pay fees are due at the time of session. Acceptable forms of payment include cash, major credit cards, and checks (with a $30 fee for any returned checks).

INSURANCE BILLING AUTHORIZATION
I hereby authorize the release of necessary medical information for insurance
reimbursement purposes for all services rendered by my provider at Anchored in Hope Counseling Services LLC. I authorize the payment of medical benefits to the provider of services. I agree to notify the provider of any changes to my coverage.

Patient Rights and Responsibilities:

At Anchored in Hope Counseling Services LLC, you have the right:
 To receive quality care regardless of age, sex, religion, race, sexual preference, or health status
 To be treated with respect
 To have access to information contained in your record and have all information handled with confidentiality and privacy
 To participate in decisions involving your care and/or to appoint another person to make decisions on your behalf should you lose the ability to do so
 To file a compliant about your care without the fear of penalty, to have your complaint reviewed, and when possible, resolved

As a Client you are responsible:
 To provide as much information as possible about your presenting concern, any past history, and other matters relating to your plan of care
 To schedule and keep appointments or call to cancel if you cannot attend
 To notify your counselor of any changes in address, phone number, or insurance coverage
 To ask questions when you do not understand explanations about your care
 To be responsible for your actions if you refuse treatment or do not follow recommendations
 To be courteous and considerate of all staff

CONSENT TO TREATMENT

By signing this Information and Consent Form as the Client or Client’s Guardian, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given the opportunity to address any questions or request clarification for any of the above information. I am voluntarily agreeing to receive mental health treatment and services for me (or my child), and I understand that I may stop such treatment or services at any time.