Informed Consent for Counseling

1. Counseling: is a collaborative process between you and a counselor to work on areas of dissatisfaction in your life and assist you with life goals. For counseling to be most effective, it is important that you take an active role in the process. Counseling activities are governed by the Texas State Board of Examiners for Professional Counselors. I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress.

 

2. Time parameters: Full sessions are scheduled for 60 minutes or 90 minutes. This time includes administrative procedures. For a 60 minute session, you will receive 45-50 minutes of direct time. For a 90 minute session, you will receive 75-80 minutes of direct time.

 

3. Confidentiality: As a Licensed Professional Counselor in the State of Texas, I am bound by the Texas Administrative Code, Chapter 681 and the Health and Safety Code, Chapter 611.In accordance with these rules: information obtained in the counseling session or in written form will not be disclosed to any outside person(s) or agency without your written permission except when such disclosure is necessary to “protect you or someone else from imminent harm” or is otherwise legally required and/or allowed by law (such as abuse of a child, elder, or disabled person or court order). If you are under 18, your parents or legal guardian(s) may have access to your records and may authorize release to other parties.

 

4. Risks: Counseling has both benefits and risks. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events in your life. Potential benefits include significant reduction in feelings of distress, better relationships, better problem-solving and coping skills, and resolutions of specific problems. Given the nature of counseling, it is difficult to predict what exactly will happen, but I will do my best to make sure you will be able to handle the risks and experience at least some of the benefits. However, counseling remains and inexact science and no guarantees can be made regarding outcomes.

 

5. Electronic Transmission: I cannot ensure the confidentiality of any form of communication through electronic media. You are advised that any email sent to me via a computer in a work-place environment is legally accessible by an employer.

 

6. Records: I am required by law to maintain records of each time we meet or talk on the phone. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. A judge can subpoena your records for a variety of reasons, and if this happens, I must comply. I can be called to testify about the contents of the records and I must comply. If you have any questions about this, please let me know. I will certainly share any information with you that I provide to an insurance provider.

 

7. Consultation: Information about you may be discussed in confidence, without revealing your identity, with other counseling professionals for the purpose of consultation and providing you the best possible service.

 

8. Fees and Payment: Fees will be collected at the time of service. I do not file with insurance. You are financially responsible for the full fee. It is my policy to keep a credit card on file at all times. I will not charge your credit card unless you have given me permission in order to pay for services rendered, fail to cancel a session within 24 hours or fail to show up for a scheduled appointment. It is also my policy to turn delinquent accounts over to collection after 90 days. If it becomes necessary to do this, there will be an additional 10% charge to the outstanding balance. The fee for any returned checks is $35 on top of the fee for services.

 

9. Cancellation: If you find it necessary to cancel an appointment, please contact me at 832-713-6830 at least 24 hours in advance. Cancellations with less than 24 hours advance notice will be charged at full fee. Note that if you fail to cancel with greater than 24 hour notice or you fail to show for a scheduled appointment, your credit card will be charged the full fee.

 

10. Emergencies: If an emergency situation for which you feel immediate attention is necessary, please contact emergency services (911) immediately or go to your nearest hospital emergency room. I will follow those emergency services with standard counseling and am available to be contacted at 832-713-6830. Please indicate when a call is urgent as calls are returned during normal business hours.

 

I have read, understood, agree, and consent to the above conditions of service stated. I have also received the notice of privacy practices on this date and have had the opportunity to ask questions about and understand these policies.