Informed Consent for Psychotherapy
[Kids & Families Christian Counseling Center, LLC 3231 Central Park West, Suite 109, Toledo, OH 43617] Informed Consent for Psychotherapy
General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who maybe subjected to these abuses.
Suspected neglect of the parties named in items #3 and #4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
RECORD KEEPING
Your records are maintained in a web-based system. What this means is your records are stored online in a secure, encrypted, HIPAA compliant system that is backed up to ensure records are not lost due to technical problems. This system provides certain benefits to client including online payment, online scheduling, and secure
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messaging to your therapist. Please ask any questions or report any concerns you have regarding online record keeping. As with any record keeping method, every foreseeable precaution has been taken to protect privacy, but there are no guarantees.
CONSENT FOR E-MAIL CORRESPONDENCE Although E-mail is a simple and efficient way to communicate and exchange information, it should never be used during a time of crisis or emergency. During your time in counseling with Kids & Families Christian Counseling Center, LLC, email exchanges with your counselor may be helpful for issues such as rescheduling an advanced appointment, providing a brief update on events/issues. While there are benefits to corresponding through e-mail, you need to be aware of, and agree to, the following provisions:
• Email accounts are checked one or two times per day, therefore information needing prompt attention should not be emailed (e.g. emergency, crisis, less than 24 hour cancellation notification)
• Kids & Families Christian Counseling Center, LLC cannot guarantee the confidentiality of the information that you send or receive via e-mail. If other people in your home or office have access to your e-mail account and sent/received emails, it is important to remember they may see the emails exchanged between you and your counselor.
• If you change your e-mail address or would like messages sent to a different e-mail account, you are responsible for informing your counselor of these changes.
IN CASE OF EMERGENCY
I make every effort to monitor my calls when I am not in the office, but there may be an occasion when you feel the need to reach your counselor and are unable to do so. If such an emergency arises, I want you to be aware of your options. You may call 911, or Zepf Center at 419-904-CARE (2273) who maintains a 24 hour helpline. Most of the area hospitals would also be able to assist you.
MY UNEXPECTED ABSENCES
I am ethically and professionally bound to ensure that you receive competent care in the event I am unable to continue to provide it for whatever the reason. Just like you, unplanned things can happen to me including sickness, accidents and even death. In the event I am ever unable to continue to provide my services to you, I have identified a trusted colleague who will manage my practice and act as a Bridge Therapist and other therapists who may offer continuing care if I am unable to.
In order to accomplish this, he/she will have access to your contact information in the event something happens to me. This person will contact you to inform you of my situation and status, offer to either meet with you and or make referrals to other practitioners whom I have identified and trust.
FEES My rate for the initial 75 minute session is $175 for individuals or family sessions. Subsequent sessions are $150 for 60 minutes.
Please be aware that your account is your responsibility. We expect payments to be paid at time of service. We accept cash, check and charge cards for payment.
Our fees may increase in the future so that we may continue to provide the highest quality of service. You will be notified of a fee increase 4 to 8 weeks prior to its implementation and given opportunity to manage your care.
CANCELLATION POLICY
If you need to cancel an appointment, please give us a 24 hour notice by calling the office or sending an email. The office phone does not accept texts. We have an active waiting list and try to use our time effectively. You will be charged the full amount for any missed appointment without this advance notice and the fee will be automatically charged to your credit card.
THEORETICAL ORIENTATION
Various theoretical orientations are employed to address the issues presented, including, but not limited to Cognitive Behavioral, Person Centered, Play Therapy and Expressive modalities using art, therapeutic games and
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animal assisted therapy.
About the therapist [Kelli Burns, M.S.Ed.,LPCC, BCPCC
I am a Licensed Professional Clinical Counselor by the Ohio Counselor, Social Worker and Marriage & Family Therapy Board, (License #E.1800918). I am also a Board Certified Christian Counselor with the International Board of Christian Professional and Pastoral Counselors. My expertise is in the area of children, teens and young adults with over 20 years experience in a variety of settings. ]
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.