If you wish, you may wait to complete this form during your initial session. Without confirmaing insurance benefits, this session may cost up to $120.
This document is intended to provide you with the ability and opportunity to give voluntary informed consent to psychotherapy. Please read this document carefully, and bring any questions or concerns you may have to your first session for discussion.
The counselor is licensed by the Texas State Board of Examiners of Professional Counselors as a Licensed Professional Counselor (LPC, License Number 70589).
The counselor does not offer medical services or advice, nor medication prescription or management.
Unless otherwise stated, all information related to the client’s identity will remain strictly confidential. In order to protect the client's privacy, the counselor will not engage or otherwise interact with the client outside those interactions that facilitate the therapeutic process.
Furthermore, the counselor will not pursue interaction with the client in such a case. If the client chooses, he or she may publically engage the counselor with the knowledge that this may or may not constitute public disclosure of the therapeutic relationship between the counselor and client.
However, there are notable exceptions as required by law. The most common among these exceptions are:
(Taken from the LPC Ethics Code: http://www.dshs.state.tx.us/counselor/CodeOfEthicsPDF.pdf)
Other notable exceptions include:
In all of the above cases, the counselor is committed to sharing no more or less than is required by law and, whenever possible, to make every reasonable effort to notify the client before the release of information or records. In any of the above circumstances, the counselor will fight to protect the client's privacy to the highest possible degree.
As is the standard of practice for mental health professionals, the counselor will occasionally consult with colleagues to ensure quality of client care and to facilitate professional development. In such consultations, clients’ identities are protected as much as possible. Upon the discovery that a consultant colleague knows the client(s) of a particular case, consultation regarding that case with said colleague will cease immediately.
Legally, a minor cannot provide consent without the agreement of a legal guardian. By law the legal guardian is considered the client even if he or she never directly receives treatment. This means that the legal guardian has all the rights and privileges normally reserved for only the individual receiving treatment.
However, the legal guardian’s unrestricted access to confidential information can be counter-therapeutic. When the minor receiving treatment is not protected by the same confidentiality normally reserved for an adult, he or she might be disinclined to share information that might otherwise contribute to the therapeutic process.
An individual who wishes to file a complaint against a Licensed Professional Counselor (LPC) may write to:
Complaints Management and Investigative Section
P.O. Box 141369
Austin, Texas 78714-1369
or call 1-800-942-5540 to request the appropriate form or obtain more information. This number is for complaints only. Please direct routine calls and correspondence to 1-888-963-7111 or to:
Texas Department of State Health Services
P.O. Box 149347
Austin, Texas 78714-9347
(Taken from: http://www.dshs.state.tx.us/counselor/lpc_complaint.shtm)
The counselor will maintain a written record of all interaction with the client with the exception of minor scheduling matters. At times, health insurance or other third party managed care organizations may require the release of records for purposes of claims or payment processing. In such a case, the counselor will interpret client requests to file with insurance as permission to release any information required for the filing process.
Please obtain the below information by
calling your insurance company.
When you call, please ask for mental health information for specific “CPT codes” as indicated. They will know what these mean. Some of the below may not be applicable.
The counselor accepts cash, check, or credit card. Except in the case of a minor, only the client will have access to her or his records no matter who pays for treatment.
If you become involved in legal proceedings requiring the counselor’s participation, the party requesting the counselor's participation will be required to pay for the counselor’s participation. The fee for court related services is $300 per hour. This includes:
The counselor's worldview is that of orthodox Christianity. That this position may trouble some and comfort others is a given. However, the Christian faith will not be "pushed" onto any client. Aside from the fact that "pushing" is not a counselor's job, the counselor is confident enough in Christian spirituality to, without pronouncing judgment, interact with other faith perspectives.
However, for clients who might find it helpful, spiritual exploration can be a powerful therapeutic tool, and spiritual matters are at times involved in client difficulties in some way. The client is encouraged to consider his or her position on discussing spirituality with the counselor and make mention of this position at the first therapy session.
Treatment provides support and guidance through the processes of healing and enrichment. The counselor is specially trained to effectively provide such support and guidance through the administration of specific techniques or therapeutic interventions.
Treatment does not but on rare occasion provide answers, advice, or instant "cures" for problems. Treatment does not require the client to engage in any behavior or activity with which she or he is uncomfortable or unwilling. Treatment does not guarantee positive results, though significant benefits are expected and are indeed the goal.
Alternatives to receiving counseling services from the counselor are available. Aside from receiving counseling services from another LPC, an LPC-Intern, or a Licensed Marriage and Family Counselor (LMFT), individuals seeking help may find beneficial counseling groups lead by an LPC, community support groups, community lay counseling, pastoral counseling, or crisis counseling. These services may be found at local hospitals, churches, schools, or other community service providers.
Treatment may reveal to the client undesirable personality traits, behaviors, or other observations he or she would rather not confront. Treatment may correlate with disruption in relationships, especially if those relationships are based on the symptoms being treated. Treatment may resolve one concern only to reveal a deeper underlying issue. Treatment may fail to produce the desired results, or it may produce other than the desired results. Treatment may impact lasting change in the client's life that is undesirable for the client.
Benefits from treatment are expected, hoped for, and worked toward. Treatment may correlate with enhanced quality of life for the client, enhanced quality of relationships, greater overall life satisfaction, and resolution of problems. Treatment is often correlated with enhanced self-awareness and an enhanced sense of self. Treatment may help the client to manage negative emotions or experiences such as grief and loss. The possible benefits of treatment are extensive and far-reaching.
The counselor will be punctual, respectful, and committed to the client's work for change. The counselor will display professionalism at or above the current standard of care. The counselor is committed to staying current in research developments of the mental health field and to the continual process of increasing the quality of care provided.
The client is expected to abide by agreements made with the counselor concerning payment for service and scheduling of therapy sessions including missed appointments should they occur. The client is encouraged and expected to arrive to session at or before it is scheduled to begin. The client is encouraged and expected to actively participate in the change process, complete homework assignments, and partner with the counselor in the treatment process. This client responsibility cannot be overly stressed. In the counselor’s opinion, the single most important element of successful treatment is the client's willingness to "work." Treatment belongs to the client, and the client has ultimate control over it so long as it is offered.
With rare exception, any form of counseling-related communication will be returned or initiated during business hours. Business hours often change. The counselor is not to be considered an emergency contact. In case of an emergency, call 911 or proceed to the nearest emergency room.
Clients are encouraged to use the online portal available at the counselor’s website at any time. Online accounts allow clients to:
By signing this document, you, the client, assert that: you have read it in its entirety; you have been notified of the potential benefits, risks and alternatives to treatment; you have been given the opportunity to refuse treatment; you have been given the opportunity to ask any questions pertaining to the content of this document; you have arrived at satisfactory answers for these questions; and you affirm this document as a contractual agreement to govern all interactions between yourself and the counselor. If any part of this contract is changed for any reason, you will receive notice and the opportunity to either accept or reject these revisions. You accept the counselor's prerogative to terminate treatment at any time and for any reason.
By signing this document, I, the counselor, affirm this document as a contractual agreement to govern all interactions between the above client and myself. I furthermore assert that I am responsible for providing notice and opportunity for the client to accept or reject any revisions made to this document. I accept the client's prerogative to terminate treatment at any time and for any reason, and I further affirm that, all conditions having been satisfied (e.g. payment for services), the time spent in therapy belongs to the client and is at the client's disposal.
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