Counseling Information and Consent Form
My name is Crystal I. Crim, and I am Licensed Professional Counselor (LPC) in Alabama, a Licensed Clinical Professional Counselor (LCPC) in Nevada, a Board Certified Telemental Health (BC-TMH) provider, and a National Certified Counselor (NCC I hold a Master of Education degree in Counseling and Guidance, with a specialization in Clinical Mental Health Counseling, from the University of Montevallo and am pursuing my Ph.D. in Counselor Education and Supervision with Walden University. I want to take this opportunity to welcome you to counseling and provide you with some information that you may find valuable. Counseling requires desire, work, and trust. We will discuss and agree on some requirements and expectations before beginning services. I believe that every person deserves the highest quality of counseling services possible without prejudice to race, gender, religion, physical challenge, ethnic origin, or income level. During our time together, we will use an integrative approach to help you achieve your goals, which may include group, individual, and family counseling.
My theoretical orientation for counseling centers around Person-Centered Theory. As I get to know you, your communication style, and your personal clinical needs, additional therapeutic techniques will be used to support your treatment. I will use what I learn about you to inform my therapeutic direction so that I can help you create short-term and long-term goals that you will work on during and outside of our sessions.
Timing and Goals of Counseling
Should we agree to meet, our professional relationship will typically consist of a once per week counseling session, lasting approximately 60 minutes, on the day and time we both agree on. Depending on your needs, sessions may be increased or decreased. However, we will work together to determine the session schedule during our initial meeting. During our initial session, we will work together to establish the goals you want to achieve and the concerns you want to address during our time together.
Counseling Session Fee
Depending on your payment method (i.e., Out-of-Pocket or Insurance), you will be expected to pay your required counseling session fee at the time of service. For out-of-pocket clients, your fee is $145/hour. For insurance clients, your fee is based on your quoted insurance co-pay. The initial counseling session fee is determined by Practice Management.
Cancellation and No-Show Fees (non-Medicaid clients)
Your counseling session date and time are assigned to you and no one else. If you need to cancel or reschedule your session, I ask that you do so 48-hours in advance. If you miss a session (i.e., No Show) or cancel with less than 48-hour notice, you will be required to pay 50% of full counseling rate the first time and the full rate the second time (unless we both agree that the session was missed due to circumstances beyond your control
After two missed sessions, you will be removed from the schedule and a termination of service letter will be mailed to you with three clinical references. This process serves two purposes. First, this process ensures you are not continuously charged for missed sessions. Second, the process allows you to think about your clinical needs.
Cancellation and No-Show Process (Medicaid clients)
If you are using Alabama Medicaid for billing, you will not be required to pay the late cancellation or no-show fees. However, after two missed sessions, you will be removed from the schedule and a termination of service letter will be mailed to you with three clinical references.
After Hours Contact
Client-initiated calls, emails, or other approved communications will be returned within 24- hours, Monday through Friday. Client-initiated communications sent Friday-Sunday will be returned during business hours on the following Monday. DO NOT CONTACT THE OFFICE IN THE EVENT OF A SAFETY OR LIFE-THREATENING EMERGENCY. CALL 911 OR REPORT TO YOUR LOCAL EMERGENCY DEPARTMENT.
Confidentiality
I am ethically bound to keep confidential anything you say in our sessions, with the following exceptions:
- If you are a danger to yourself or others;
- If you have or plan to harm a child or other vulnerable individuals;
- If someone is abusing you, as defined by DHR;
- If I am ordered to do so by a court of law;
- If you sign a release to disclose information to another entity/person; and/or
- For consultation purposes.
I will maintain awareness and sensitivity regarding cultural meanings of confidentiality and privacy and speak with you about how, when, and with whom information is to be shared. I will not share confidential information without your prior consent or sound legal or ethical justification, as you have the right to privacy. I will only gather information from you when it is beneficial to the counseling process.
Recording
Our sessions may be audio recorded and will be destroyed following our session. These recordings allow me to self-assess my clinical work to ensure I am providing the most effective therapeutic care to you as my client. If you do not wish to be recorded, please let me know before the beginning of each session.
Records
Alabama Clients: I am required by the Alabama Board of Examiners in Counseling to maintain client records regarding services for no less than 3 years following the end of our clinical relationship. Records will be shredded at the end of this 3-year period.
Nevada Clients: I am required by the State of Nevada Board of Examiners for Marriage and Family Therapists & Clinical Professional Counselors to maintain client records regarding services for no less than 5 years following the end of our clinical relationship. Records will be shredded at the end of this 5-year period.
You are also legally allowed to view your clinical record. If you would like a summary of your clinical record, please let me know. We can review this summary together, which will allow you the opportunity to ask questions.
Termination
To ensure therapy is effective, regular attendance is required. Ongoing assessments regarding your progress will be discussed with you. Typically, once your treatment goals have been reached, we will discuss termination of services. However, there are times when termination may take place for reasons other than successful completion of treatment. Those include, but are not limited to:
- Current therapeutic process does not fit your need;
- Current therapeutic process is not beneficial;
- Non-compliance with mutually developed treatment goals and procedures;
- You do not pay your bill;
- You become combative, violent, or otherwise abusive, or litigious; or
- If the therapeutic relationship is compromised.
Satisfaction of Services
If you are dissatisfied with my services, please do not hesitate to let me know. If we cannot come to an understanding and resolution, it is my duty to refer you to another care provider.
If you have any questions now or in the future, please feel free to ask them at any time. Your signature on this form indicates that you have been informed about the above terms and understand them clearly, as well as provide your consent for treatment.