Informed Consent for Education and Counseling and Psychotherapy Handoff
I am currently able to provide short-term counseling about your sexual wellness. Courtney Johnson-Benson, MAEd, CDP, is a trusted and knowledgeable person who can educate and counsel without judgment or fear of stigma. I am currently finishing coursework in one of the two only accredited Human Sexuality Ph.D. programs in The United States and am currently training to be a Certified Sex Counselor through the Sexual Health Alliance and AASECT. I will be offering a discounted rate for sex counseling until I complete my training and receive my certification.
Consultation
15-minute free consultation for all clients after completing the intake form.
Any additional consultation with collaborating professionals will cost $25 every 15 minutes.
Client(s) will be billed $25 per 15 minutes if additional consultation is necessary after the initial consultation.
Collaborative consultations with other professionals (such as gynecologists, urologists, psychiatrists, psychologists, therapists, etc.) can maximize a favorable outcome for the client and are strongly encouraged prior to intake and/or psychotherapy handoff for that client budgets appropriately for collaborative consultation. Consultation will be billed to the client(s).
Other Fees
Phone Calls/Emails: Phone calls and emails to schedule, reschedule, and cancel appointments are free. Phone calls with clients under 10 minutes are free. Emails written that take less than 10 minutes are free.
Phone calls made to collaborating providers are billed at $25 for every 15 minutes to the client (s). Emails and phone calls longer than 10 minutes should be billed as an appointment.
Payment
Payment is accepted by credit card, and your credit card will be charged before the session is completed. Credit cards will be kept on file using a secure system. Visa, Discover, and MasterCard are accepted.
Course of Treatment
Our counseling relationship will commence with a 15-minute assessment session that will take place over the phone, using video conferencing software, or in person in Canton, Ohio. Clients begin counseling with the counselor after completing all the appropriate paperwork. Our initial appointment can often involve all members about the reason for seeking counseling services, and all people in the initial session need to sign this document. If, however, after the initial appointment or a series of appointments, the counselor decides to continue to see only one client as their primary client, then a special release needs to be signed, or a new account needs to be created to authorize or remove authorization for the records of the initial appointment to be shared with other members of the relationship. After the initial appointment, the counselor may contact a collaborating professional via a 15-minute consultation or may save that service for when it is relevant.
If, after the assessment session, it is determined that a course of sessions with Courtney Johnson-Benson will not be appropriate, an appropriate referral (if available) will be made. Not all clients who schedule an assessment session are appropriate for a course of treatment with Courtney Johnson-Benson.
Clients are commonly encouraged to find or remain with an existing individual or couples counselor throughout treatment with Courtney Johnson-Benson. The counseling provided by Courtney Johnson-Benson aims at an adjunct that focuses explicitly on the clients' or relationships' sexual issues, while an individual or couples counselor works on many other issues that may potentially be better addressed in person.
Assessment is an ongoing process, and assessment might continue to unfold throughout the course of many follow-up sessions. Unless a psychotherapy handoff would be therapeutically helpful or if the client is planning on applying for reimbursement from their insurance company and requires a diagnosis, treatment is generally determined not by diagnosis but through assessment and evaluation.
As a sex counselor, I generally aim to be brief in my work with a client; however, the length of sessions varies, and I believe counseling lasts as long as it takes to resolve the issues and as long as progress is being made, which cannot always be predicted. Deeply engrained or longstanding issues take a significant time to resolve.
The treatment usually winds down to a period of maintenance and then termination. Courtney Johnson-Benson will discuss maintenance and termination plans with the client if and when this period approaches. Courtney Johnson-Benson often follows up with clients via secure email at approximately six months post-termination if it is relevant or necessary. It is the policy of The Cognition Collective, LLC and Courtney Johnson-Benson not to mail out letters using US Mail for termination or contact unless specifically requested by the client.
Cancellation Policy
There is a standard cancellation policy that requires 24-hour notice for a cancellation. Half of the fee will be charged if less than 24 hours is given for a cancellation. The full fee is charged if a client does not show up for the appointment. This policy is upheld, and by signing this document, you authorize your credit card to be charged when you cancel with less than 24 hours notice or do not show up for your appointment and do not cancel.
Emergencies are considered on a case-by-case basis. If a client cancels three times throughout the course of treatment, it is assumed that now may not be the appropriate time for your session. The counselor will address the repeated cancellations with the client and decide how to proceed. Please keep cancellations to a minimum.
Confidentiality
I hold in confidence all information obtained, generated, or documented in the course of providing counseling with the following exceptions:
a. Threat of serious harm to self or others;
b. Reasonable suspicion of child abuse, or neglect of a child, or abuse, neglect or exploitation of an incapacitated or dependent adult;
c. Court order;
d. Voluntary written release signed by client or guardian; and
e. During supervisory or peer consultations.
A special note regarding sensitive sexual content involving a child or incapacitated or dependent adult: counsel by state authorities will be sought if a client reveals that they are in possession of any type of pornography or explicit images/media of a child or incapacitated or dependent adult or have exchanged any type of pornography or explicit images/media with a child or incapacitated or dependent adult. Depending on the state you reside in, the therapist is likely required by law to notify the police and other appropriate authorities. This includes peaking/talking/texting/conversing with a minor in an explicit manner or exchanging explicit photos or videos with a minor. Please note, in some states, a minor is considered under the age of 18.
Providing counseling at a distance raises some unique challenges in case of an emergency. If an emergency occurs, Courtney Johnson-Benson may speak to a member of your family or another clinician without your consent. If there is good reason to believe you are at imminent risk of harming yourself, Courtney Johnson-Benson is legally responsible for informing a crisis center, hotline, emergency room, police, etc., and will contact the appropriate authorities in the area where you are located.
Many clients choose to be seen in a couple or family situation. Couple and/or family client records are the property of the couple and/or family, and the couple and/or family has access to those records. The client must be aware that things that are said to the counselor can become part of the couple and/or family record and that all members of the client couple and/or family have access to the couple and/or family record. Counseling records will contain information about both/all parties and, therefore, will not be released unless both/all parties sign a written consent form or unless there is a court order.
I value your confidentiality greatly, and in the event of an unexpected event causing death or permanent impairment of the counselor, client records and files will be managed by another legal entity of the LLC, which will provide a referral and transfer files if necessary. By signing this form, you authorize this to occur.
I guarantee that many steps have been taken to protect your confidentiality. Both of the online platforms that are used are encrypted, and my location is confidential and secure. Your role in protecting the confidentiality of our sessions will be to ensure that our sessions do not take place in the presence of anyone but the client and that you take reasonable and appropriate steps to ensure that your session is held in a private and confidential location. Additionally, it is expected that you do not participate in any other activities (such as driving, doing dishes/laundry, etc.) while in session. I also abide by The American Association of Sexuality Educators, Counselors and Therapists (AASECT) Code of Conduct for Members.
Theoretical Views & Client Participation
At The Cognition Collective, we adopt an Embodied Cognition Guidance Approach to foster a personal connection with learning, offering customized plans for navigating intricate discussions and enhancing sexual and relational wellness. Our method significantly emphasizes client engagement, leveraging personalized guidance, client-centered practices, and effective communication strategies to boost satisfaction and well-being. Self-awareness and acceptance are pivotal for achieving peace and contentment, yet the journey to these goals varies greatly among clients, ranging from a few sessions to years. Active participation in counseling, including working on discussed topics and avoiding mind-altering substances before sessions, is crucial for success. Your personal development is our utmost priority, and we support any decision to change or terminate counseling to ensure the most beneficial outcome. We're committed to your healing and growth, offering flexibility in managing your therapeutic journey.
Social Media and Internet Boundary Policies
Since my counseling practice is mainly based online, some unique challenges come up that are important to be aware of prior to starting sessions with me. Please read this document in order to understand the expectations of the client and the therapist while interacting online.
Interacting on social media and the internet with clients can compromise your confidentiality, can blur the boundaries of our counseling and professional relationship, and can impact our working relationship. My primary concern is your privacy, and engaging in social media with you could compromise your privacy without my knowledge.
If there are things from your online life that you would like to share with me, please bring them to our sessions. We can review and explore them together during our session time. Here are a few policies about social media and Internet boundaries that I would like you to review:
Friending
I do not accept friend requests from current or former clients on any social media sites (including, but not limited to: Facebook, Twitter, LinkedIn, Snapchat, Instagram, Friendster, etc.)
Following
If you use an easily recognizable name on Twitter or blog commentaries, and you decide you want to follow my professional stream of tweets or blogs, we may discuss this and its impact on our therapeutic relationship. If you choose to follow me, please note that I will not follow you back due to privacy concerns and appropriate professional boundaries.
"Googling" and Use of Search Engines
It is not part of my regular practice to search for clients on the internet using Google, Facebook, or other search engines. Extremely rare exceptions may be made during times of crisis (i.e., if I have reason to believe that you are in danger and you have not been in touch with me via our usual means) or when I believe it helps accentuate the client-therapist relationship. Also, I ask that you do not search or "Google" me beyond the information that you need to have to make a decision on whether I am the right counselor for you. The internet has an unlimited amount of information about us as individuals, and I ask that you respect my privacy and not do extensive searching on me or my personal matters.
Location-Based Services
There are some privacy considerations if you are using location-based services on your mobile device. Keep in mind that using a location-based service on your mobile device (even if you are unaware of it being activated) could violate your confidentiality and privacy.
Review Sites
You may find my practice on various review sites such as Yelp, Google Business, Facebook or other places that list businesses. Some of these sites have review options that allow users to rate their experience. According to Kolmes (2010), many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is not a request for a testimonial, rating, review, etc. While you have the right to express yourself on any site you want to, due to confidentiality concerns, I cannot respond to any review on any of these sites, whether it is positive or negative. Because of privacy concerns, it is also likely that I will never see these sites and I ask that you discuss with me your feelings and reviews of our work directly instead, as this can be an essential part of our counseling relationship.
Communication
Please use email or the secure messaging system through www.thecognitioncollective.com to communicate with me on the internet and send attachments to the cognitioncollective@courtneyjohnson-benson.com email. You may feel free to call me at any time as well. You can also feel free to text me regarding scheduling. Any texts you send me will be part of your medical record. Please note that I may not immediately respond to emails, texts, and voicemails if they are not emergencies. Also, please be mindful and do not text or call past 8 pm EST.
Appropriate Boundaries
Utilizing the internet as a way to communicate can often raise some boundary issues not present in traditional face-to-face counseling relationships. Clients often feel free to express themselves more openly and profoundly Clients can utilize telephone, chat, and video conferencing sessions to express more intimate and complex thoughts, feelings, and behaviors. Because inappropriate and compulsive behavior on the internet is often one of the issues clients struggle with in their regular lives, it can often be an issue within the counseling relationship. Please remember that all emails and texts will be part of the clients' records, and the counselor will document and address any inappropriate communication in session. These policies have been developed to protect your privacy and keep our counseling and professional relationship confidential.
Please feel free to bring up any questions or concerns you have regarding the information found in this document when we have a session. As new technology, apps, programs, and resources develop and as the Internet changes, it may be necessary for this document to be updated. If this document is updated, I will notify you and send you a copy of the updated policy.
Tele-Counseling and Electronic Counseling (E-Counseling) Informed Consent Form
By signing below, I consent to engaging in tele-counseling and/or electronic counseling with Courtney Johnson-Benson as part of my sexual wellness counseling. I understand that "tele-counseling " and "electronic counseling" includes the practice of mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications such as the telephone, cellular phones, the Internet, and various programs such as Zoom, Google Meet, and other relevant programs.
I understand that I have the following rights with respect to tele-counseling and/or electronic counseling:
(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or counseling or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
(2) The laws that protect the confidentiality of my health information also apply to tele-counseling and electronic counseling. As such, I understand that the information disclosed by me during the course of my counseling is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. I also understand that the dissemination of any personally identifiable images or information from the tele-counseling and/or electronic counseling interaction to other entities shall not occur without my written consent.
(3) I understand that there are risks and consequences from tele-counseling and electronic counseling, including, but not limited to, the possibility, despite reasonable efforts on the part of my counselor, that: the transmission of my health information could be disrupted or distorted by technical failures; the transmission of my health information could be interrupted by unauthorized persons; and/or the electronic storage of my health unauthorized persons could access information. I also understand that the programs listed above have their own policies that might interfere with confidentiality and I am fully aware of the risks associated with working with these programs. In addition, I understand that tele-counseling and electronic counseling-based services and care may not be as complete as face-to-face services. I also understand that if my counselor believes I would be better served by another form of psychological services (e.g. face-to-face services) I will be referred to a practitioner who can provide such services in my area, if available. Finally, I understand that there are potential risks and benefits associated with any form of counseling, and that despite my efforts and the efforts of my counselor, my condition may not improve, and in some cases may even get worse.
(4) I understand that tele-counseling and electronic counseling is not the recommended modality of counseling for many clients including, but not limited to: clients who are actively suicidal or homicidal, clients with active substance abuse issues, clients with severe psychiatric conditions, clients in violent situations, etc. I understand that if I am identified as falling into the previous categories or others, that I may be offered a referral to a therapist who utilizes a modality that will be better suited to my needs. Additionally, I may be asked to consent to an additional "Safety Plan" in order to protect my safety, given the nature of the risk I present with.
(5) I understand that I may benefit from tele-counseling and/or electronic counseling, but that results cannot be guaranteed or assured.
(6) I understand that I have a right to access my counseling information and copies of records in accordance with state law.
(7) I understand that there are many ways to communicate with my counselor, but the most secure ways to communicate with her are through either a telephone call OR the secure email system through https://www.thecognitioncollective.com .
While security is often a perception, and nothing truly can be guaranteed due to the laws of our government, the secure messaging system and the cognitioncollective@courtneyjohnson-benson.com email accounts have also had reasonable steps taken to make them data privacy-compliant and secure. Courtney has taken every measure in their power to ensure that your information and data is secure, and by signing this form, you acknowledge that there is still a possibility that your information could be accessed.
I have read and understood Courtney Johnson-Benson Sexual Wellness New Client Intake Form and the "Social Media and Internet Boundaries Policy" and have discussed any concerns or questions pertaining to the information in this packet with my counselor. (Each adult needs to sign).