Agreement of Terms
Please read and agree that you have fully read and understand the information below.
RISKS AND BENEFITS: Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, there may discussion about personal issues which may bring about uncomfortable emotions such as sadness, anger, and guilt. However, the benefits of counseling can outweigh any discomfort encountered during the process. Some of the possible benefits are reduced emotional distress, improved personal relationships, and specific problem solving. I cannot guarantee these benefits, of course. It is my desire, however, to work with you to attain your personal goals for psychotherapy/counseling.
COUNSELING: I provide short-term/ long-term counseling designed to address many of the issues clients are dealing with. Your first visit will be an assessment session in which you and I will determine your concerns, and if both agree that I can meet your therapeutic needs, develop a plan of treatment. Should you choose not to follow the plan of treatment provided to you by your Therapist, services to you may be terminated. My goal is to provide the most effective therapeutic experience available to you. If at any time you feel that you and I are not a good fit, please discuss this matter with me to determine if transferring to a more suitable Therapist is right for you. If you and I decide that other services would be more appropriate, I will assist you in finding a provider to meet your needs.
APPOINTMENTS: Appointments are typically scheduled on a weekly basis and are approximately 60 minutes long. Services will be provided in home/office unless otherwise discussed. More frequent sessions or an intensive outpatient schedule are available if determined appropriate. If you must cancel or reschedule your appointment, I ask that you call me (404.800.1218) at least 24 hours in advance. This will free your appointment time for another client. Late cancellation (less than 24 hours before) and/or no-show appointments are billed to the client for the full amount. In the case of illness or other emergencies, please notify me as soon as possible on the day of the appointment to prevent charges. In that event, we can schedule another session as needed. Please leave a message if you get voice mail.
FEE SCHEDULE: I am not operating at this time on an insurance panel. Therefore, payments must be in the form of self-pay.
PAYMENT: Payment of fees is expected at least 24hours in advance before time of each appointment. Payment must be made before your session begins. Insurance is not accepted-Cash or Credit--- Paypal, ACH, etc.
EMERGENCIES: You may encounter a personal emergency which will require prompt attention. In this event, please contact me regarding the nature and urgency of the circumstances. I will make every attempt to schedule you as soon as possible or to offer other options. Because clients may be scheduled back-to-back, it is not always possible to return a call immediately. However, I will make every effort to respond to your emergency in a timely manner. If you are experiencing a life-threatening emergency, call 911 or have someone take you to the nearest emergency room for help.
CONFIDENTIALITY: I follow all ethical standards prescribed by state and federal law. I am required by practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted below: Discussions between a Therapist and a client are confidential. No information will be released without the clientʼs written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the Therapist has a duty to disclose, or where, in the Therapistʼs judgment, it is necessary to warn or disclose; fee disputes between the Therapist and the client; a negligence suit brought by the client against the Therapist; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to the attention of the Therapist when you and the Therapist discuss this matter further. Byagreeing to this Information and Consent Form, you are giving consent to the undersigned Therapist to share confidential information with all persons mandated by law providing your mental health care services, and you are also releasing and holding harmless the undersigned Therapist from any departure from your right of confidentiality that may result.
DUTY TO WARN/DUTY TO PROTECT: If my Therapist believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to my Therapist to contact any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger.
CONSENT TO TREATMENT: By agreeing to this Client Information and Consent Form as the Client or Guardian of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receiving mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time.