Consent and Services Agreement

Welcome to counseling! This form provides information about our services: Please review it carefully, and feel free to ask us any questions!

About the Services

The potential benefits of counseling are many and include improved personal functioning, stress management, reduction in anxiety and depressive symptoms, improvement in relationships, self–‐image, mood, and the attainment of personal goals. However, in some cases persons have reported feeling worse after counseling. Clients understand that healing and growth is difficult, and some discomfort will likely be a part of the counseling process.

Confidentiality / Personal Health Information

All communications and records with your counselor are held in strict confidence. Information may be released, in accordance with state law, when (1) The client signs a written release indicating consent to release; (2) The client expresses serious intent to harm self or someone else; (3) There is reasonable suspicion of abuse against a minor, elderly person, or dependent adult; (4) To acquire payment for services or for billing purposes, or (5) A subpoena or court order is received directing the disclosure of information. To protect your privacy to the greatest extent of the law, it is our policy to assert either (a) privileged communication in the event of #5 or (b) The right to consult with clients, if at all possible, before mandated disclosure in the event of #2 or #3.

Electronic Communication

Electronic communications, both telephone and Internet (including email, text, instant messaging), are not secure methods of communication, and there is some risk that one’s confidentiality could be compromised with their use. Counselors sometimes communicate with clients using these mediums. If you would prefer to not be contacted by telephone, email, text, or other messaging, please inform your counselor and we will honor this request.

Client Follow Up

Your counselor may “follow-up” with you after counseling has ended. 1 month, 3 month, or 6 Month follow-up calls may be made to check in with clients and see if gains made in counseling have been maintained. In addition, someone you may receive solicitation for feedback on your counseling experience. If you would prefer to not be contacted, simply inform your counselor and your preferences will be respected.

Scheduling and Cancellations

Scheduling an appointment is a commitment that both counselors and clients honor. Appointments can be cancelled or rescheduled if 48 hour notice is provided. If sessions are cancelled or rescheduled with less than the required notice, or if a client misses a session, the client agrees to pay for that session (insurance will not pay for missed appointments). Please know that exceptions to this policy may be made in the instance of a serious medical emergency, or serious family emergency. Additionally, if there are three late cancellations (being done within 24 hours of appointment time or no-shows) or more within a 6 month period, the client may be discontinued from treatment services.

Work Agreement

It is agreed that the client shall engage in the counseling process as an important priority in his or her life. Suspension, termination, or referral shall be discussed between counselor and client for a pattern of behavior showing disinterest, lack of commitment, or for any unresolved conflict or impasse between counselor and client.

Conflict Resolution

We work hard to make sure that you have a positive counseling experience. However, if a conflict occurs, it is agreed that any disputes shall be negotiated directly between the parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences with a mutually acceptable third–‐party mediator. If these are unsatisfactory, then the parties shall move to arbitration, and then binding arbitration, choosing an arbitrator mutually agreeable to both. Litigation shall be considered only if and after all of these methods of resolution are given a good faith effort and are unsatisfactory.

Emergency Contacts

Your counselor will establish emergency contacts for you, such as the phone number and location of a family member. Your counselor will also obtain alternative methods for contacting you, such as a mobile phone, or work phone number. These emergency contacts may be used if the counselor perceives a need. If you are in crisis and cannot reach your counselor, please contact emergency services (911), Behavioral Health Response’ 24/7 mental health crisis line at 988, or go to your nearest emergency room.

Service Fees

Payment is due at the time of your scheduled session. Any Insurance co–‐pays or deductibles are due at the time of the session. Payment can be made in cash, check, or by electronic funds payments through services such as Venmo, Paypal, CashApp, etc. You and your counselor can identify the method at time of payment.  Unfortunately, we cannot extend credit or provide services unless payment is made in conjunction with those services. Clients understand they are fully responsible for all fees if insurance or other vendor does not pay for any reason.

Court Action / Legal Fees

NOTE: There may be a time when your therapist is subpoenaed to testify or produce records on your behalf. If that case should arise, the below fees would be assessed and charged. Although, responsible for the fees described herein, it is important to note that your therapist is required to testify to the facts and that such facts may not necessarily or solely be in your favor.

• Retainer Fee: $2500 due at least 7 days prior to any court appearances
• Preparation (including Records Review and Preparation) time: $250/hour
• Phone calls (outside of initial inquiry/cause for subpoena): $250/hour
• Depositions: $250/hour
• Time required in giving testimony: $250/hour
• Mileage: $0.57/mile
• Time away from office due to depositions or testimony: $250/hour
• All attorney fees and costs incurred by the therapist as a result of the legal action.
• Filing a document with the court: $150
• Court presence requested, but canceled/rescheduled within 72 hours: $500 in addition to the $2500 retainer already provided
• Records Search and Retrieval: $26.85
• Copying of Records: $0.57/per page

We, the counselor and client, have read and fully understand and agree to honor this agreement, including the commitment to negotiate and mediate as stated above, and will respect one another’s views and differences in their outworking. We have also agreed to an initial definition of work and to the fee to be paid by the client.