Counseling Informed Consent Form

Welcome and 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 address your concerns.

COUNSELING. Counseling is a process of social engagement between a professional psychotherapist or psychiatrist, known as counselor or therapist, acting to help a client seeking to learn more about himself or herself, exploring difficulties, and to understand the society that surrounds himself or herself in reaching defined positive goals for a better chance to become a productive member of society.

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 53 minutes. Counseling sessions are on the reservation and by appointment. In case the client will not be able to attend the scheduled appointment, he/she should communicate 24-hours prior appointment or he/she will be charged 100% of the session fee. A late-cancellation/no-show fee will be applied under, but not limited to, the following circumstances: “forgetting” you had an appointment scheduled, scheduling conflicts that require you cancel your appointment, major school exams, etc. I will try to give you as much notice as possible if I need to reschedule our appointment.

If a session starts late, the time will be truncated to meet other clients needs and scheduled appointments.

Evening sessions are highly requested and any repeated late cancelations and no shows during evening hours will result in limited hours of scheduling. 

Medicaid/Medicare clients 

As Medicaid and Medicare clients are unable to be charged for no shows/late cancelations, after two no shows/late cancelations within a 45 day period, clients will be removed from counselor's caseload and provided a referral. 

Inactivity

Clients that are inactive for 30 days or stop responding to correspondence will be archived, this is to ensure that all clients waiting for counseling receive timely care.

After hours and off schedule sessions are available via appointment.

I am sometimes able to travel to your home or office, to see you in person. This is a great option for those who prefer in-person sessions and wish to have an added layer of privacy and discretion. This service is provided in Houston and the surrounding areas and is not covered by insurance.

*Client identity, location, and payment must be finalized prior to session.

 

Reminders

Please be advised phone/text/e-mail reminders are only a courtesy. You are ultimately responsible for your appointment date and times. Stating that you did not receive a phone/text/e-mail reminder for your appointment is not a valid excuse for missing the appointment, and a no-show/ late cancel fee will be assessed. Additionally, if you need to miss an appointment, please call/text/e-mail me directly at least 24 hours before your appointment.

*** All cancellations made less than 24 hours before your appointment time will be assessed a late-cancellation/no-show fee.

 

***As Medicaid and Medicare clients are unable to be charged for no shows/late cancelations, after two no shows/late cancelations within a 45 day period, clients will be removed from counselor's caseload and provided a referral. 

FEES. Fees are charged on a per session basis. We may directly bill your insurance company by informing us. At this time, insurance is only accepted for individual sessions. If you are planning to pay, here are our schedule of fees:

Individual Counseling $100

Your first initial visit will be an assessment session which you and I will determine your concerns, and if we both decide that I can provide your therapeutic needs, then we will work on treatment objectives together. Appointments are typically scheduled on a weekly basis.

Marriage and or Family Counseling $150

No show/Late Cancelation fee:$100

Client-home/office visit: $200 per hour.

I do not complete FMLA or disability paperwork without seeing a client at least 8 times. Completing this documentation is not covered by insurance  and will incur out of pocket costs which must be paid at the time of request. 

• Court Witness (varies)

In unusual cases you may become involved in litigation that may require my participation. My focus in providing counseling is on treatment and healing. It is NOT my intention to become involved in cases that require evaluation or testimony. When subpoenaed, I may obtain my own legal counsel. If I am required to appear in court or conference via telephone, the client or guardian associated with the subpoena/court request will be required to pay in advance for the preparation time at a rate of $200.00 per hour. In addition, my fee, whether I testify or not, is $800.00 for a half day (4 hours) and/or $1600.00 for a full day. A minimum of $1000.00 is to be paid  before my preperation begins as this takes away from other client's mental health services. Because I must cancel other appointments for this appearance and preparation, this payment will not be refunded for any reason.

• Administrative fees

$20.00 + 1.00 (per page) Copy of client file

$65.00 Letter Writing

$125.00 Written report (minimum charge)

RELATIONSHIP. The relationship required for effective counseling is strictly professional. This is for the best interest of the parties. The therapist cannot have any other relationship with the client than a professional one. 

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.