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Informed Consent for Counseling Services

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The counselor-client relationship is unique in that it is a highly personal and at the same time, a contractual agreement. It is therefore 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.

1. The Therapeutic Process
The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, be uncomfortable or stressful. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, sadness, or fear. There are no miracle cures and no way to avoid discomfort, if you choose to engage in therapy. What’s more, I can’t promise that whatever brought you to counseling will change, if we work together. I can only promise to do my best to guide and support you in making the changes you want to achieve, as well as to help you clarify what it is that you want for yourself.

 

2. Risks, Benefits, and Alternatives of Counseling
Generally, the risks of counseling include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, because the process often involves discussing or remembering unpleasant, difficult, or painful aspects of your life. Another risk of counseling is that as you start to bring about change in your life, you and/or your loved ones might notice this change and feel that you can no longer be the same person you were before. At times this can be unsettling or cause conflict in important relationships.


Moreover, my approach to counseling includes a focus on the here-and-now, and a firm belief that you hold the power to choose how you see the world and how you interact with it. This approach often contradicts accepted ideas about the ways in which we are shaped by life experiences. It can make your experience working with me feel very different than what you expected, and our relationship can look very different from other counseling relationships you may have had. “Different” can be good, but it can also be scary, unsettling, and frustrating.

However, counseling has benefits for many people who undertake it. It can be helpful in reducing feelings of distress and fear, improving your satisfaction in interpersonal relationships, and building strong personal awareness and self-knowledge. My approach is often particularly effective in helping people identify and implement new solutions to old, seemingly unsolvable problems, as well as healing past hurts, and building self-esteem, confidence, and recognition of their own power and freedom. Importantly, many of these benefits emerge over time.

You should know that there are alternatives to counseling and/or other formal therapeutic services, which you can pursue at any point. Several of these alternatives are consistently helpful to many people, and most can be used together with, or instead of formal services. These alternatives include regular exercise, meditation and mindfulness practices, self-help and peer-support programs, journaling, and interacting with animals (e.g., through equine therapy). There are other alternatives as well.

3. Your Responsibilities
Counseling requires an active effort on your part. To increase the likelihood of success, you will have to maintain an open mind, a willingness to learn, and the motivation to do the work necessary to make a change. You’ll need to show up to appointments on time, and ready to focus on the work we undertake. You’ll also be expected to be clearheaded and avoid being under the influence of substances (whether legal or illegal) ahead of our appointments. In some situations, you might also need to work on things we talk about outside of sessions. Even when it’s uncomfortable or painful, you’ll need to try to be open and honest about your needs, concerns, situation, and about your experience in our work together.

4. Appointments and Sessions
Once we have agreed to work together, we will usually schedule one appointment or session, lasting 50 minutes, once per week or once every other week, at a time we agree on. Our sessions will be held virtually over a secure version of Zoom. The time scheduled for your appointment is assigned to you and you alone. If you are late to a scheduled appointment with me, that appointment will still need to end on time.

If you need to cancel or reschedule a session, I ask that you provide at least 24-hours’ notice. If you miss a session without canceling, or cancel with less than 24-hours’ notice, my policy is to charge the full fee for the session as though you had attended it, unless we both agree that you were unable to attend due to circumstances beyond your control.

The first 2-4 sessions may involve an evaluation of your needs, which requires that I ask you questions and work to learn about your background, experiences, and goals. By the end of the evaluation, I will be able to offer some initial impressions of what our work might include, and how long it might take. At that point, we will work together to identify goals for our work together and make a plan to reach those goals. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my approach or perspective on our work together, we should discuss them whenever they arise.

Because your appointments are your time, I will never invite another person into our sessions, without first discussing this and obtaining your permission. Likewise, you shouldn’t allow others to attend or be present for your sessions, without informing me in advance. If you choose to invite someone else to our session or give me permission to invite someone into a session, anything discussed in that session will be known to that third person. I will not be able to guarantee the privacy of anything we discuss in the presence of someone else. Because we will be meeting virtually, you should take special care to attend appointments in a private space, where others are not present or able to listen in. I will only attend our appointments from a private workspace.

5. Virtual Therapy
Holding sessions remotely, via Zoom, has become common in the aftermath of the Covid-19 pandemic. There are many advantages to virtual sessions, including convenience and access to special care. However, you should be aware that there are drawbacks to virtual therapy sessions, as well. When held virtually, your privacy may be harder to protect during sessions - it will be up to you to ensure you are accessing therapy from a private location, and no one can overhear us. It may also be harder for me to help you, if we are not in the same space and you become very upset or emotional. Before beginning therapy, I may ask you to provide the contact information of someone you trust to support you if this happens. In addition, I can only provide virtual therapy sessions to you under the following conditions:

  • You have adequate access to reliable internet service and a device on which to access therapy

  • You can consistently access therapy in a private space

  • You are located in Mississippi or Massachusetts while accessing therapy - these are the only states in which I am licensed and can provide therapy to you

  • You do not have any neurological conditions or sensory disabilities that would impede our ability to communicate remotely

 

If at any point your situation changes and you are unable to continue virtually, I may suggest we pause therapy, or refer you to a provider you can work with in person.

 

6. Contacting Me Between Sessions
The best way to contact me is by email or by calling or texting me. However, you should know that I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my voicemail and your call will be returned as soon as possible. It may take up to 24 hours for non-urgent matters.

If, for unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or feel unable to keep yourself safe, you can call the 988 Suicide and Crisis Lifeline, go to your local hospital Emergency Room, or call 911. I also recommend that your familiarize yourself with the crisis services available in Mississippi (https://www.dmh.ms.gov/help/crisis-services/) or in Massachusetts (https://www.mass.gov/info-details/mental-health-crisis-support). I will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering my practice.

7. Privacy, Confidentiality, and Privilege
According to Mississippi law (2020 MS Code, Title 73, Chapter 30, Section 17), information I receive in the course of our work together is privileged and confidential. I cannot share this information with anyone, except under the following conditions:

  • With your written consent

  • f you can’t consent, (because you are under the age of 18, or in the case of your death or disability) with the written consent of your parent, legal guardian or conservator, or other person authorized by the court.

  • When you tell me you are planning to commit a crime, or to harm yourself or someone else.

  • If you tell me you are involved in abuse or neglect of children, people with disabilities, or elders.

  • When a court or law requires that I disclose information.

  • For research purposes, so long as you are not identified in the research.

  • To defend against a lawsuit, malpractice claim, or other formal complaint you initiate.

  • As necessary to provide you with the counseling services. For example, some information about you might be shared to facilitate virtual sessions using a third-party application, when I contact you, or when you pay for sessions. Other information might be shared if I need to consult with a colleague about the best approach or strategy for your situation.


8. Special Conditions of Services for Children and Families
Special rules and laws apply to counseling services, and the counselor-client relationship, when the client is a child or a person under the age of 18. If you are a child, or a parent pursuing services for your child, it is important that you are aware of these rules. The law requires that for minor children, where legal custody is split (joint) between parents or guardians who are no longer married or cohabiting, I need the consent of both parents prior to the child being seen. If you have sole custody or primary custody of the child for whom you are arranging counseling, I may ask to see your custody paperwork to ensure you can consent to services. If you seek insurance reimbursement for “out of network” counseling services, and your former spouse holds the policy under which you would be reimbursed, you should also be aware that information about your child’s counseling will be shared with them.

Regardless of whether you, as a parent, consent to services, your child cannot be forced into counseling. The relationship only works if the client – the child – agrees to participate and feels confident in the privacy of what they share in counseling. For this reason, my policy is to obtain the verbal or written consent of your child, and to decline to provide services to a child who does not consent to those services. Importantly, though you have legal right to access your child’s counseling records, you should be aware that doing so may interfere with your child’s willingness to participate in counseling. If I am working with your child, I will make every effort to safeguard your child’s privacy, providing information to you only when it is critical for you to know (e.g., when your child is in danger, contemplating harm, or needs your help), or when your child agrees to share something. I strongly recommend that you respect this boundary.

If you and your child’s second parent are currently undergoing separation or divorce, or if a custody dispute exists, you should let me know. Likewise, you should inform me as soon as possible about child welfare agency involvement in your family’s life. In addition to their impact on your child’s well-being, these situations often have legal consequences for my ability to provide counseling services, as well as the privacy and confidentiality of the services I provide. For instance, counseling records are often subject to subpoena in contested divorce and custody cases. Child welfare agencies often seek to verify the child’s involvement in counseling, and thus, may seek access to the child’s record.

 

9. Special Conditions for Couples Therapy
If you are seeking couples therapy, you should be aware that the therapy process will be different from what you may have experienced in individual therapy, and from the notice above, in several important ways.


Couples’ counseling is shared equally by both partners and serves the relationship rather than either partner’s individual needs. If either partner needs individual therapy, it should be provided by someone other than the couple’s therapist. I may recommend that you engage in individual therapy and may ask your permission to speak to your individual therapist. Similarly, both partners in the relationship need to consent to therapy, and both own the records for therapy. That means neither partner can consent (on their own) for couples’ therapy records to be shared with anyone else, and neither can continue couples’ therapy if their partner quits. Finally, couples’ therapy can be more challenging to conduct virtually. In the office, the therapist can easily intervene to help calm things down if they get too intense. This is much harder to do when folks are in their own space, and the therapist is a face on a screen. If a couple’s relationship includes frequent, intense conflict, it may be unhelpful (or even harmful) to conduct couples’ therapy sessions virtually.

10. Voluntary Participation
By signing below, you indicate that you have read this Agreement and the Notice of Privacy Practices, understand, and agree to their terms. You can change your mind and withdraw this consent at any time, by telling me that you’d like to withdraw your consent or notifying me of your decision in writing. If you withdraw your consent, I will no longer be able to work with you.

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NOTICE OF PRIVACY PRACTICES
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Effective August 1, 2024

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully.

1. My Commitment Regarding Your Health Information
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

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  • Make sure that protected health information (“PHI”) that identifies you is kept private.

  • Give you this notice of my legal duties and privacy practices with respect to health information.

  • Follow the terms of the notice that is currently in effect.


I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in your electronic health record, and on my website.

2. How I May Use and Disclose Health Information About You
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.​​​


2. (A) Certain Uses and Disclosures Which Would Require Your Authorization

  • Psychotherapy Notes: I do NOT keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and thus, cannot disclose or release psychotherapy notes for any purpose, including at your request. I do not record, nor document verbatim any content of conversations with counseling clients.

  • Marketing Purposes: I will not use or disclose your PHI for marketing purposes.

  • Sale of PHI: I will not sell your PHI in the regular course of my business.


2. (B) Certain Uses and Disclosures Which Do Not Require Your Authorization
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons. Unless it is unsafe for me to do so, I will make a reasonable and timely effort to inform you about the need to make such a disclosure before disclosing any information about you. By law, I may make disclosures without your authorization for the following reasons:

  • For Treatment, payment, or health care operations: Federal privacy rules allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s treatment, payment, or health care operations. I may  disclose your protected health information to facilitate or improve your care, to obtain payment for care I provide, and/or as part of the course of operating my practice. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition. Importantly, although disclosures for treatment purposes are not legally limited to the minimum necessary standard, I will seek your permission to make a disclosure (e.g., for the purpose of referral or consultation) that necessitates sharing significant information about your, or includes more than the minimum information necessary.

  • Lawsuits and disputes: If you are involved in a lawsuit or court action, I may be required to disclose health information in response to a lawful court order, after making a reasonable and timely effort to inform you about the order. 

  • When disclosure is required by state or federal law: when the use or disclosure complies with, and is limited to the relevant requirements of law. This may include compliance with mandatory reporting requirements for communicable disease, child, elder, or dependent adult abuse, or likely harm to self or others. 

  • For health oversight activities: including health care record audits and investigations.

  • For homeland security purposes, including: ensuring the proper execution of military missions;  conducting intelligence or counter-intelligence operations; or for other legitimate, valid national security purposes. 

 

2. (C) Certain Uses and Disclosures Which Require You to Have The Opportunity to Object
Disclosures to family, friends, or others. By law, I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part.  Except in an emergency, I will always seek your permission and authorization to make such disclosures, and will seek to limit these disclosures to only necessary information.

 

3. Your Rights with Respect to Your PHI

You have several rights to limit or restrict the use of your PHI.

 

  • The Right to Request Limits on Uses and Disclosures of Your PHI: You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

  • The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full: You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

  • The Right to Choose How I Send PHI to You: You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

  • The Right to See and Get Copies of Your PHI: Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

  • The Right to Get a List of the Disclosures I Have Made: You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

  • The Right to Correct or Update Your PHI: If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

  • The Right to Get a Paper or Electronic Copy of this Notice: You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.​

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