Services For Child/Teen

We are committed to providing you with quality care. Please take a few minutes to read the following information that will explain confidentiality policies and procedures to you. If you have any questions, please ask and we will be happy to clarify any of the information in this form. Please sign and date this form acknowledging that you have read and fully understood the confidentiality and privacy information and are consenting to begin services. Thank you.

Consent to Treatment: I, voluntarily, agree to receive or authorize an assessment, treatment or service or care or treatment and authorize Shine Bright Counseling and Counseling to provide such care, treatment or service as are considered necessary and advisable.  I understand and agree that I will participate in the planning of the care, treatment or service and that I may stop such care, treatment or services that are provided by Shine Bright Counseling and Consulting.

If you are seeking treatment as a function of a court order, we require a hard copy of the court order. If you are seeking treatment for your child and are divorced, separated, or currently involved in any legal proceedings, you must submit a hard copy of your divorce decree and any additional orders currently in effect that supplement the decree. In so doing, you are documenting that you have the legal right to seek treatment for your child.

If you or your family’s therapy has been ordered by a court, there are further limitations imposed on your rights as a client. These may include the decision to delineate the number of sessions available to you or require your participation at a specified frequency. Under these circumstances, a report of your attendance and your progress in therapy may be required.

Emergencies: You may encounter a personal emergency that may require prompt attention. Your clinician will make reasonable efforts to respond to your emergency in a timely manner. If it is after-hours or on a weekend, or you reach the office voicemail during an emergency situation, please go to the nearest emergency room, and ask for assistance regarding a mental health emergency or call 911.

Appointments: Services are by appointment only. You are responsible for keeping your appointment and timely arrival. In the event that you cannot keep an appointment, it is your responsibility to call/text your clinician at least 24 hours in advance to cancel or reschedule. No-shows or cancellations within 24 hours will be charged the regular session rate.

Any type of audio/visual recording is prohibited in therapy sessions, without prior discussion and consent.

Confidentiality: You are protected by the confidentiality laws in Texas, which state that anything discussed during sessions and meetings is privileged information and cannot be shared with anyone else without your consent. This also means that we cannot tell anyone whether you are receiving assistance from Shine Bright Counseling and Consulting, PLLC without your permission.   Possible exceptions to confidentiality include those provided by laws, including but not limited to child abuse, abuse, neglect, or exploitation of the elderly or the disabled; AIDS/HIV infection and possible transmission; criminal prosecution; child custody cases.

These records are confidential pursuant to certain legal and ethical limits and clinical parameters, and the HIPAA Notice of Privacy Practices provided to you in this document. Within these limits, the information revealed by you will be kept confidential. No information will be released without your written consent and authorization unless mandated by law. Possible legal exceptions to confidentiality include, but are not limited to, the following situations:

1- If you reveal information that indicates, you are a danger to yourself or someone else necessitating a duty to protect or duty to warn.

2- If you reveal information about child abuse, neglect, elder abuse or sexual exploitation.

3- If you are in therapy as the result of a court order, unless otherwise stated in the court order.

4- If I receive a subpoena or a court order to disclose information.

5- If you provide written permission or direction to release your record.

Duty to Warn/Duty to Protect: If a Shine Bright Counseling and Consulting, PLLC counselor believes that my child is in any physical or emotional danger to themselves or another human being, I hereby specifically give consent to such counselor to contact any person who is in a position to prevent harm to my child or another, including, but not limited to, the person in danger.

By signing this Information and Consent form, you are giving consent for Shine Bright to share confidential information with all persons mandated by law or for whom you have provided written permission and you are releasing and holding Shine Bright Counseling and Consulting, PLLC harmless for any departure from your right to confidentiality that may result.

Minors and Parents: Clients under 18 years of age who are not emancipated from their parents, should be aware that the law may allow parents to examine their child’s treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For all individuals, privacy in therapy is often crucial to successful progress and there can be long-lasting negative effects if a client feels their confidentiality has been breached. It is the clinical preference of Shine Bright Counseling and Consulting, PLLC, if necessary, to release summaries, with general information about the treatment goals and progress of the child’s treatment and his/her attendance at scheduled sessions. If the clinician feels that the child is in danger or is a danger to someone else, s/he will notify the parents and/or appropriate authorities of the concern.

Consent to Treatment and Confidentiality: By signing this Client Information and Consent Form as the Client or Guardian of the Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing, and I understand that I may stop such treatment or services, not under court order, at any time. I acknowledge receipt of this privacy notice:

Telemental Health Informed Consent: I consent to Telemental Health if we mutually determine that it is an appropriate means to communicate. I understand that Telemental Health is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a  client who are located in different physical locations. Shine Bright Counseling and Consisting, PLLC utilizes Doxy. Me. This internet platform is encrypted to the federal standard, PIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Doxy. I am willing to attest to HIPAA compliance and assume responsibility for keeping the live video interaction secure and confidential. If you choose to utilize this technology, Shine Bright PLLC will give you detailed directions regarded how to log in securely.  Shine Bright Counseling and Consulting, PLLC requests that you sign onto the platform at least 5 minutes prior to your session time to ensure a prompt start time and strongly suggests that you online communicate through a computer or device that you know is safe. 

I understand the following with respect to Telemental Health:

1) I understand that I have the right to withdraw consent at any time without affecting my right to further care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks and consequences associated with Telemental Health, including but not limited to, disruption of transmission by technology failures, interruption and/or breach of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be not recording of any of the online sessions by either party.  All information disclosed with sessions and written records pertaining to those sessions is confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to Telemental Health unless a legal exception to confidentiality applies.

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experience a mental health crisis that cannot be resolved remotely, it may be determined that Telemental Health services are not appropriate and a higher level of care is required.

6) I understand that during a Telemental Health session, we could encounter technical difficulties resulting in service interruptions.  If this occurs, end and restart the session.  If we are unable to reconnect within ten minutes, the session will be rescheduled.

7) I understand that my counselor may need to contact an emergency contact and or appropriate authorities in case of emergencies.

Complaint Process:

If you believe that Shine Bright Counseling & Consulting, PLLC has violated your privacy rights, you have the right to file a complaint. You may complain by contacting:

You may also file a complaint with:

U.S. Department of Health and Human Services 200 Independence Avenue, S.W.

Washington, D.C. 20201

(800) 368-1019 (toll free)

You must file your complaint within 180 days of when you knew or should have known about the event that you think violated your privacy rights.

You will not be retaliated against if you file a complaint. Effective Date: April 14, 2020