Client Services Agreement

for Short Term Therapy Services

This agreement applies to short-term counseling services provided by the Wendt Center for Loss and Healing. Included here is information about the counseling process, as well as the associated benefits and risks. Please read through this document thoroughly.

Informed Consent for Treatment

By signing this consent for treatment form, I understand and agree to the following:

1. Participate in short-term counseling which is a maximum of two sessions.
2. The short-term therapist I meet with will in most cases not be my future therapist if I am seeking long-term therapy services.
3. Short-term counseling at the Wendt Center is intended to provide immediate emotional support, psychoeducation, and consultation around grief and trauma.
4. After completing two short-term sessions, I must inform my short-term therapist if I would like to remain on the waiting list for future, long-term services, otherwise I will be discharged.
5. If I am on the waiting list for long-term services, I understand I am no longer considered an ‘active’ client of the Center until the time of assignment to a new long-term therapist. I understand that it is my responsibility to acquire other therapy or support during this waiting period and that my short-term therapist will not be available to support me during this time. The Wendt Center will provide resources and referrals to other providers upon request.
6. Undergo therapy services and understand that I may end treatment at any time. I understand that my therapist may want to discuss this with me, and that I reserve the right to end treatment without discussion.
7. In some situations, a therapist may decide that it is not in my or their best interest to continue therapy. While this happens rarely, the therapist also has the right to terminate a therapeutic relationship for clinical cause. Reasons for this can range from therapy focus is no longer within the scope of trauma or grief specific services to interpersonal dynamics or conflicts within the therapeutic relationship. If this happens, appropriate recommendations will be provided to the client for transfer to another therapist or for services outside of the Wendt Center.
8. The Wendt Center therapist is required to make a professional diagnosis for multiple reasons including but not limited to, the development of a treatment plan, third-party/ insurance billing, funder requirements and may be required to submit that diagnosis to the relevant payer (funder or insurance).
9. The Wendt Center therapist cannot guarantee the results of treatment. However, I understand that my therapist will continually assess my need for treatment and will clearly state reasons, goals, and objectives for continuing treatment or will communicate an assessment that treatment is no longer needed.
10. There may be some challenges in participating in mental health treatment. These might include addressing painful emotional experiences and/or feelings and being challenged or confronted on a particular issue. I am aware that I can discuss any challenges with my therapist at any time.
11. Be prepared to focus on and discuss therapy goals and issues related to the scope of grief and/or trauma treatment and be an active participant in the therapy process. I am expected to attend appointments on time, and I will not be seen if I am more than 15 minutes late to session. In such cases, this session will be considered a No Show.
12. The Wendt Center therapist will not conduct a therapy session if I am under the influence of drugs or alcohol, engaging in violent or dangerous behavior, or communicating in language that is offensive. Any such behavior places my enrollment in services in jeopardy for discharge based on the discretion of the therapist.
13. The Wendt Center therapist will not offer court testimony, provide fitness assessments or custody recommendations, write qualifying opinions for the court system on behalf of clients, nor appear voluntarily for legal proceedings.
14. If participating in teletherapy services, the Wendt Center therapist reserves the right to decide if participating in teletherapy services is not in my best interest clinically and will arrange for in person sessions.
15. The Wendt Center will be using an approved, HIPAA compliant vendor platform to provide teletherapy, and to receive teletherapy, I must also use the approved platform using both video and audio capability which allows the therapist and client to see each other during the session.
16. During teletherapy, it is my obligation as a client to be in a safe space where I can openly and privately participate in teletherapy, otherwise the session will not occur. If this is not the case, the therapist reserves the right to terminate the session. I also agree to inform my therapist of the address where I am located at the beginning of every teletherapy session. I also understand that I must be physically located in a jurisdiction where my therapist is licensed to practice (DC, MD, or VA), otherwise the session will not occur.
17. If I am having suicidal or homicidal thoughts, or in a crisis, I will inform my therapist immediately who will work with me to ensure my safety and access needed services. If I am participating in teletherapy, I understand that if we cannot address my status remotely I will access emergency services independently or understand that my therapist may contact emergency personnel to ensure my welfare.
18. The Wendt Center does not provide 24-hour crisis care. In the case of an emergency during non-office hours, I will need to contact the District of Columbia’s emergency Access Help Line (1-888-793-4357), Suicide and Crisis Lifeline (988), Crisis Link (1-800-784-2433), or dial 9-1-1 in the case of a life-threatening emergency.
19. I agree to abide by the Wendt Center No Show and Cancelation policy. If I must cancel an appointment I will provide no less than 24 hours’ notice by either contacting my therapist, the front desk or alerting the cancelation system in the patient portal. If a client experiences two No Shows or a pattern of cancelations within a three-month period, enrollment in services will be in jeopardy and the therapist can move to discharge.
20. If I have a grievance with my therapist, I will first attempt to communicate this directly to them. If the grievance is not satisfactorily resolved, I understand that I have the right to speak with a supervisor, request a new therapist, and/or speak directly with the Wendt Center’s Clinical Director.
21. This Informed Consent is not intended to be “all inclusive” of aspects of one’s mental health treatment. It is only intended to provide some basic information to assist in deciding to engage in treatment.

Limits of Confidentiality

The information that you share with your therapist and/or other Wendt Center staff is confidential. In most cases, information cannot be released to another party without your written consent. However, local and federal law and professional codes of ethics require that in certain circumstances, information can and will be shared without your permission. These circumstances where information cannot be kept confidential include:

1. Suicide: if you are assessed to be a danger to yourself; cannot guarantee your physical safety against the intention of suicide; and/or have immediate suicidal plans. Actions may be taken to ensure your safety.
2. Homicide:if you are assessed to be a danger to others; cannot guarantee their safety; and/or have immediate, specific plans to cause fatal injury/harm to another person. Actions may be taken to protect the safety of others.
3. Child or Elder Abuse/Neglect: D.C. law requires ALL mental health providers to report all suspicions/knowledge of child or elder abuse/neglect to the appropriate authorities.
4. Court Order/Subpoena: your therapist can be required to relinquish a copy of your written Mental Health Record to the appropriate Courts. Mental health providers can also be subpoenaed to testify in court without your consent.
5. Minors can consent to outpatient mental health treatment in the District of Columbia without parental permission or notification provided the minor is knowingly and voluntarily seeking the services and the provision of those services is clinically indicated for the minor’s well-being (DC Code section 7-1231 §7-1231.14) This includes not sharing information with parent(s)/caregiver(s)/case manager(s) without the child’s permission.
6. Client medical records are destroyed after the legally required duration.
7. Confidential mental health information may also be used within the Wendt Center for Loss and Healing without your written permission for the purpose of coordinating services within the agency and delivering high quality care. This includes but is not limited to consultations and training with internal interns, supervisors, and other providers at the Wendt Center. In the case of any external consultations, training or case conferences with others, information will be de-identified to further protect confidentiality.

Health Insurance Portability and Accountability Act (HIPAA)

1. I understand that I may request a copy of the Wendt Center for Loss and Healing’s HIPAA Notice of Privacy Practices at any time, view it at any time, or view it on the Center’s website at www.wendtcenter.org.
2. As a client of the Wendt Center, I understand that I consent to receiving necessary communications about my services including appointment reminders, surveys, closure notices, reminders about making payment, and other appointment related communication. A separate form (which follows this agreement) will allow me to opt into or out of other types of communications, and I can change my selection to those optional communications at any time by emailing forms@wendtcenter.org to request a new “Additional Communications Form”.

Fee Agreement

Assignment of Benefits

I authorize and request that payment of benefits by my primary insurance company and my secondary insurance (if any) be made directly to the Wendt Center for Loss and Healing for services furnished to me or my dependent in situations where the Center has a contractual agreement with my insurance. I authorize the Wendt Center for Loss and Healing or my insurance company to release any information required to process my claims.

Payment

I understand that when appointments are booked for insurance clients, the Wendt Center is only able to provide an estimated client cost. I understand that my insurance company may only cover a portion of the total bill, and I further understand that I am responsible for all charges not covered by my insurance(s). This may include deductibles, co-pays, co-insurance, etc. I understand that it is my responsibility as the client to confirm benefits and coverages with my insurance. If client payment is required, payment is due prior to service, including teletherapy sessions. If my services require payment, I understand that I will need to submit a valid credit card to be kept on file and charged by the Easy Pay system at the time of service. I understand rates for services can be found on the Wendt Center website or by asking at the front desk. Fees are updated annually. I also understand that I will be charged a $35 fee for any check returned or reissued.

Client Balances

Clients may only carry a balance for 2 sessions. Clients will not be eligible for services until the balance is paid in full.

Changes in Insurance Coverage

I understand it is my responsibility to notify the Wendt Center immediately of termination of coverage or any other change in coverage. Changes in payment that are not reported will result in the client being billed. If you are covered under a grant and the grant expires, you will be given notice and an opportunity to change your payment type to continue services.

Emergency Contact Information

I agree to provide contact information for at least one Emergency Contact, to be used in the case of a medical emergency. I will provide this information using the form which follows. I can update these Emergency Contacts at any time by emailing forms@wendtcenter.org to request a new “Emergency Contact Form”.

I have read, understand, and agree to the above policies. I understand my rights and responsibilities as a client and the rights and responsibilities of my therapist. I understand that I am financially responsible for services received from the Wendt Center for Loss and Healing and I agree to pay for any portion of my treatment that my insurance plan or assigned third party payer does not cover. I agree to participate in therapy at the Wendt Center for Loss and Healing and understand that I can end therapy at any time.

Below please provide contact information for at least one emergency contact. This information will only be used by the Wendt Center for Loss and Healing in the event of a medical emergency. 

Please do not use the same information from the caregiver above unless no other emergency contact has been identified. If you are a minor, the emergency contact should be a legal adult but does not have to be your caregiver.

As a client of the Wendt Center for Loss and Healing, I understand that I consent to receiving necessary communications about my services.

The Wendt Center also regularly sends out communications regarding upcoming programs, events, new services, as well as fundraising appeals. Please carefully review the options below and make a selection by checking the box or boxes.

Regardless of your selection you will in no way be prevented from receiving services or future services from the Wendt Center as a result.

If you wish to opt out of all additional communications, please confirm you have only selected the top box above. You may choose to change your selection(s) at any time by requesting a new version of this form to complete either at the front desk or by emailing forms@wendtcenter.org.