INFORMED CONSENT
GENERAL INFORMATION

Welcome!  As a new client we look forward to collaborating with you and your family.  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 and treatment will work, and what you can expect which is outlined in this consent.  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 or signing at the end of this document.  You or your child may remember unpleasant events.  This may be hard, and we can work together to process it.  I cannot promise that you and/or child’s behavior or circumstance will change.  I can promise to support you and do my best to understand you or your child’s behaviors.

BACKGROUND INFORMATION

I am a Licensed Professional Counselor with a master’s in counseling.  I am licensed with the state of Arizona, licensed number 17075 and have been in the field for 8 years.  I will collaborate with you within my scope to help you develop a treatment plan that meets your needs.  If, however I feel you may need more specialized care or a higher level of care outside my scope, I will work with you on referring you to an appropriate provider.

THERAPEUTIC RELATIONSHIP

The client/counselor relationship is unique in that it is exclusively therapeutic.  It is inappropriate for a client and a counselor to spend time together socially, to connect on social media, to bestow gifts, or to attend family or religious functions.  The purpose of these boundaries is to ensure that you and I are clear in our roles for your treatment and that your confidentiality is maintained and kept safe.  If there is ever a time when you believe that you have been treated unfairly or disrespectfully, please talk with me about it.  Sometimes misunderstandings can result in hurt feelings.  I want to address any issues that might get in the way of therapy as soon as possible.  This includes administrative or financial issues as well.  If there is ever a time when a dual relationship is identified, we will work together to discuss next appropriate steps such as boundaries or termination of the therapeutic relationship and a referral (if needed).

THE THERAPEUTIC PROCESS

Your treatment will begin with one or more assessments and then based on those assessments; a treatment plan will be developed.  Each session afterwards will be based on this plan.  This is done so we can get an understanding of the issues, your background, and any other factors that may be relevant.  During treatment you will begin to understand the connection between you/or your child’s thoughts, feelings, and behaviors.  You may also learn to understand the root of some of your thinking patterns and behaviors.  Painful memories may come up, but we will work together to find coping skills to help you process.  You are an active member of your treatment team; you have the right and the obligation to participate in treatment decisions and in the review and revision of your treatment plan.  You also have the right to refuse any recommended treatment or to withdraw consent to treat and to be advised of the consequences of such refusal or withdrawal.  If there are other members of your treatment team, we will discuss if it is best to include them in the process and have you fill out a release of information. During treatment I may photograph (sand tray) or scan in your work/drawings to upload to your chart. If you do not want this, please let me know so we can discuss it.

TREATMENT PROCESS FOR MINORS

Minors will receive an initial assessment and treatment plan.  However, depending on developmental level, treatment may look differently.  Talk therapy is not always the best approach for some children and even some adults that may have developmental needs.  We will use appropriate therapeutic modalities during treatment such as Sand Tray Therapy, Play Therapy, or Art Therapy.  The guardian is also an active participant and observer in treatment.  Parents, you are expected to participate in treatment when it is deemed appropriate.  Children under a certain age may always have their parent in the session and actively involved.  Teens are encouraged to have autonomy and it is encouraged for them to have a confidential relationship with their therapist.  Minors are part of a family system, decisions about care, medical, educational, etc., must be made by the child’s parents/legal guardians.  If there is a parental separation or divorce, both parents MUST consent, in writing, to counseling services.  We have a separate form for you to do so.  We invite and encourage both parents (as they are able) to participate in the treatment process.  If one parent retains sole legal custody, this parent MUST provide documentation of this for therapy to proceed.  In the case of joint custody, both parents MUST consent to treatment (A.R.S. § 25-403(H)).  If the child is with a foster parent, then there must be a NOTICE TO PROVIDER and consent from the DCS guardians.  Remember, parents have a right to records, one or both parents may request it if they have legal custody.  ARS 36-2272.  ARS 25-401.

EAP CLIENTS

Prior to starting treatment, I will need an authorize code.  You understand your EAP provider only will authorize a limited number of sessions.  Part of treatment for EAP clients is finding ongoing support after your authorization ends.  You also understand that not everyone is appropriate for EAP, and the counselor may recommend a referral if needed.

INSURANCE AND DIAGNOSES

Although I do not always find standard diagnosis helpful in formulating a direction for treatment, insurance companies require a diagnosis to cover what they deem “medically necessary treatment.” Treatment is often limited to individual psychotherapy, but in some cases can also cover family therapy.  In both cases, the primary “patient” will be given a diagnosis as close as possible for the symptoms and complaints as they match the diagnostic manual used by clinicians.  I am always happy to discuss the diagnosis given, it is implications and how much utility it has in any given situation.  Please feel free to ask me about your diagnostic or service codes you may find on notes, invoices, or bills if they are unclear to you.

LIMITS OF CONFIDENTIALITY/CONFIDENTIALITY AGREEMENT

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing (a Release of Information) 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:

1.     If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a way there is a substantial risk of incurring serious bodily harm.

2.     If a client threatens grave bodily harm or death to another person.

3.     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.

4.     Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5.     Suspected neglect of the parties named in items #3 and # 4.

6.     If a court of law issues a legitimate subpoena for information stated on the subpoena.

7.     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.

If you are a minor, your parents may be legally entitled to some information about your therapy.  I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.  If you report to me that you are being harmed, it is my duty to report to keep you safe.

CONSULTATION

Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. I belong to two consult groups and also get voluntary one on one reflective consultation monthly. Information about you may be shared in this context without using your name or any other identifying information.

OUTSIDE OF THE OFFICE

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.  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.

CLIENT RIGHTS

You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment.  You have the right to ask questions about any aspects of therapy and about counselor specific training and experience.  You have the right to terminate treatment at any time after discussing concerns with your provider.

RECORDS

You have the right to request that a copy of your file be made available to any other health care provider at your written request.  Any request for records will require a signed Release of Information form indicating reason for request.  If a minor’s parents are divorced, both parents need to fill out the request unless one party has full legal custody.  For DCS children, the DCS legal guardian will need to fill out the ROI.  Records include but are not limited to, progress notes, treatment plan, and assessments.  We do have the right to limit and/or refuse sharing records based on A.R.S. § 12-2293.  Records will be provided in accordance with confidentiality guidelines and will be provided within 30 days of written request.  There is a standard record fee of $5.