Healing Moments Counseling! 9766 Fallon Ave NE Suite 201 Monticello, MN Phone (763) Fax (763) !

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1 Healing Moments Counseling 9766 Fallon Ave NE Suite 201 Monticello, MN Phone (763) Fax (763) INFORMED CONSENT AND CLIENT CONTRACT Welcome and thank you for choosing Healing Moments Counseling. Today s appointment will take approximately minutes. During this first session your counselor will explain to you clinic policies and procedures, obtain a detailed intake and answer any questions that you may have regarding the counseling process. We realize that starting counseling is a major decision and you may have many concerns or questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. Therapist Qualifications Kathleen Massmann has earned a Bachelor of Arts Degree in English and Philosophy and a Masters of Science in Mental Health Counseling from Capella University. She is licensed by the State of Minnesota as a Licensed Professional Clinical Counselor. Kathleen has over 10 years of clinical experience in treating adolescents, adults and families using individual, couples and family therapy. Kathleen practices person-centered therapy, Cognitive Behavior Therapy, as well as EMDR therapy;other treatment approaches are used depending on the person or condition presented. Shannon Breitkreutz has earned a Bachelor's Degree in Social Work from Saint Cloud University and a Masters of Arts in Professional Psychology from the University of Saint Thomas. She is licensed by the State of Minnesota as a Licensed Psychologist. Shannon has over 12 years of clinical experience in treating individuals, couples and families She utilizes Cognitive Behavior Therapy and Family Therapy techniques to assist clients in meeting their therapeutic goals. Shane Tratechaud has earned a Bachelor of Science in Psychology from Michigan State University and a Masters in Professional Counseling from Argosy University. He is licensed by the State of Minnesota as a Licensed Professional Counselor. Shane has over 20 years of experience working with individuals (ages 4+), couples and families. He utilizes a integrative therapeutic model to meet the needs of each client, as well as a Play Therapy approach with younger children. Juli Teien has earned a Masters Degree in Marriage and Family Therapy from Alfred Adler Graduate School. She is licensed by the State of Minnesota as a Licensed Marriage and Family Therapist. Juli has over 13 years of clinical experience in treating a variety of clients aged 4 and over. Julie utilizes a variety of tools and modalities while working with her clients including; sand tray therapy and equine assisted psychotherapy. Katherine Sand has earned her doctoral degree in Clinical Psychology from the Minnesota School of Professional Psychology. She is licensed by the State of Minnesota as a licensed psychologist and has over 12 years of clinical experience. Kate has experience with children, adolescents, adults, and couples. She utilizes approaches to fit the needs of individuals and families, including client centered, play therapy, EMDR, insight oriented, and solution focused techniques. Kate has a strong background working with diverse populations.

2 Please Note: A Licensed Professional Clinical Counselor, Licensed Professional Counselor, Licensed Marriage and Family Therapist or Licensed Psychologist cannot prescribe medication or advise you about any medical issues. You will be referred to your own primary care physician to answer all medical questions. Your therapist cannot advise you on any legal matters and will suggest you seek our legal counsel for all legal questions. In the event that you require assistance with mental health issues outside the scope of your therapist's practice experience, you will be referred to at least three qualified resources. Please advise your therapist if you are currently in therapy with another therapist, as your permission for consultation will be required before therapy services can begin. The process of psychological consultation referred to as psychotherapy, requires the creation of a therapeutic contract. Within this contract the following will be agreed to: KM ST SB JT KS (Therapist) agrees to treat you with respect, and to apply his/her knowledge and abilities to help you with the issues presented. He/She also agrees to practice ethically and maintain your privacy and confidentiality while adhering to state guidelines. You agree to come to your appointments, to pay your fees and to work toward your therapeutic goals. CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential, with the following exceptions: Information (diagnosis and dates of service) shared with your insurance company to process your claims. Information you and/or you child or children report about physical, sexual abuse or elder abuse; then, by Minnesota State Law, your therapist is obligated to report this to the Department of Children and Family Services. Where you sign a release of information to have specific information shared. If you provide information that informs your therapist that you are in danger of harming yourself or others. If you provide information regarding sexual exploration by a health care professional. Information necessary for case supervision or consultation. When required by law. A court order for specific information, signed by a judge in a pending legal case. Treatment results for court-ordered therapy. If State or Federal Law authorizes the release of your records An investigation or disciplinary proceeding with a professional association, licensing board or law enforcement agency. To ensure a high level of care and professional practice, your therapist may seek clinical supervision or case consultation with their peers. The therapist may discuss facts in the case, but no identifiable information regarding the client will be disclosed. Signature(s) Date:

3 Late Cancellation and No-Show Policy Healing Moments Counseling maintains a strict 24-hour cancellation policy. It is our policy to bill all sessions that the client fails to show for when 24-hour notice has not been given. This bill will go directly to the client, not to the insurance provider. ONLY the following conditions will result in charge(s) to your credit/bank card: Failure to pay for an attended session within 7 business days (your normal counseling rate will apply) Failure to pay for a missed session (without notice/no-show) within 7 business days: $ Failure to pay for a session that was canceled less than 24 hours from the scheduled start of the session within 7 business days: $150 To cover a returned check: Amount of check + Bank charge of $34.00 per returned check To pay for a scheduled telephone session (charged on the date of the session): (your normal counseling rate will apply) Credit Card Number: Exp Date: Security Code: ** Please note that your first session copay, coinsurance or deductible fee will be charged to the credit card listed above. All future payments can be made via check, credit card or cash*** I understand that if I fail to make payments owed for attended or telephone sessions, if I fail to show for a scheduled appointment without notification, or if I cancel a session less than 24 hours from the start time of the session, and do not make the required payment(s) within 7 business days, Healing Moments Counseling LLC, has my permission to charge the card listed above accordingly. I understand that if I am having difficulty paying I can speak with my therapist about alternative arrangements. Furthermore, I give permission to Healing Moments Counseling LLC, to communicate with my credit card company regarding these charges, if necessary. Cardholders Printed Name: Cardholders Signature(s) Date A copy of this document will be provided to you upon request. As with all client information, this document is kept in strict confidence

4 FINANCIAL/INSURANCE ISSUES: As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that you pay your co-pay or 50% of the fee at the beginning of each session. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If your balance exceeds $ we will need to ask that you pay for services when rendered. After 60 days any unpaid balance will be charged 2% interest a month (18% APR). In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to: Fee schedule Insurance cost per session Intake Session- $ Therapeutic Session- $150-$175 Phone Consultation- $45.00 per half-hour (phone sessions cannot be billed through insurance and will be the sole responsibility of the client) Self-Pay cost per session Intake Session- $100-$150 Therapeutic Session- $75-$125 Phone Consultation- $45.00 per half-hour (phone sessions cannot be billed through insurance and will be the sole responsibility of the client) Signature(s) Date: ***Healing Moments Counseling has a sliding fee available to clients who will not be using insurance to pay for sessions. This fee is payable at the beginning of each session.***

5 The Therapeutic Relationship An important aspect of the therapeutic process is the relationship that develops between the client and therapist. As with any new relationship, it may take time to trust and feel safe enough to share freely. If the relationship does not develop after a reasonable amount of time (3-4sessions), the therapist would be happy to offer referrals to a few providers that may be a better fit for you. If you were to encounter your therapist in any public place outside of therapy, your therapist will be careful not to acknowledge you or the relationship or engage in any conversation in order to protect your privacy and confidentiality. Exceptions to this would require the written permission for a very specific purpose discussed in advance, or in an emergency situation which may determine that confidentiality must be broken within the limits of the law to protect your personal safety, the possibility of you harming others, or to receive appropriate psychiatric care. Dual Relationships The therapeutic relationship is a professional relationship and as such, cannot not be a social or business relationship at any time. If a client has had a previous social or business relationship with your therapist, you will be referred immediately to other providers of mental health services. Your therapist cannot compromise the integrity of the therapeutic relationship in any way that would impair objectivity, clinical judgment, or the therapeutic effectiveness of treatment that would be detrimental to a client. To order to protect our therapeutic relationship, psychotherapy does not include physical contact. This means that we do not ordinarily touch one another as any part of therapy. Your therapist will limit contact to an occasional greeting, such as a handshake. Length of Therapy Psychotherapy sessions are generally scheduled once per week or as needed, and may be adjusted to meet your current issues and treatment goals. Please report any changes in your condition or behavior to your therapist throughout the course of therapy, as this may alter the scheduling of therapy sessions. If you feel the need to increase or decrease the frequency of sessions or to end counseling, please feel free discuss this with your therapist at any time. The First Sessions In the first few sessions, your therapist will ask a wide variety of questions designed to get to know you and learn about your personal history. The therapeutic relationship is unique in that you are expected to talk freely and openly about yourself. The therapist s job is to listen, select, sort, make observations and reflect your feelings so you may see yourself more clearly. The object of this process is the reorganization of your thinking, feelings and behavior to facilitate movement toward your goals. Within the first few sessions, treatment goals will be developed together. Your input is an essential part of this process. Please be aware that your therapist may take notes during your session, which serve to recall what was discussed in the session. Please note: Psychotherapy sessions should not be held when anyone is under the influence of a mind or mood altering substance. Violence (physical or verbal) is never acceptable. Your therapist reserves the right to discontinue a session at any time and call the proper authorities, if necessary. Clients will still be responsible for the full session fee.

6 The Therapy Process Therapy is a process that involves work in, and outside of, the therapy session for the client. The change process requires a commitment of time and the completion of tasks to move forward. Periodically, you and your therapist will review your treatment goals in order to evaluate the progress being made and to decide whether any adjustments need to be made toward your desired goals. Termination As you approach your treatment goals, you should have the skills, strategies and encouragement to make the desired changes you have chosen for your life. Although your therapist can assist you through this process, ultimately only you can make the decision to change. (Please note: If the therapist determines that treatment is no longer effectively serving the needs or interests of the client, a decision to end therapy will be made.) As the end of therapy approaches, you and your therapist will discuss discontinuing therapy with the understanding that you may choose to return to therapy as needed or be referred to other mental health providers. You have right to end therapy at any time and for any reason. Please feel free to discuss this with your therapist so any necessary referrals can be provided. Following termination, your file will be officially closed. You will be sent an or letter notifying you of this. However, you will be able to resume therapy or receive referrals at any time, should you so choose. If, for any reason or at any time, you would like to see a different therapist, please feel free to discuss this with your therapist. You will be provided with the names of at least three other therapists who may better serve your needs. Therapist Communication and Availability General business hours are Monday-Friday, with available appointments scheduled throughout the day. Your therapist may schedule your appointment on another day, as needed. Your therapist will utilize a secure voice message service to receive incoming calls. Messages are checked throughout the day and will be returned as time permits. Calls during the evening or weekends will generally be returned the following business day. All therapists utilize a HIPAA compliant , encrypted service. It is suggested that the you provide is not a work or school related , please consider using an address that you have exclusive access to. If you prefer encrypted s, please notify your therapist and your request will be honored. Please note that while text messages maybe exchanged, this form of communication is not secure and confidentiality cannot be assured. Please limit text message communication to scheduling information only. Due to the nature of electronic communication, messages can and do get lost occasionally through no fault of sender or receiver. If you are expecting a message and have not heard from your therapist after 24 business hours, please resubmit your message. As a sole practitioner, your therapist may occasionally need to re-schedule your appointment due to an illness, unexpected event, or personal commitment. Every effort will be made to contact you in advance should this occur. Additionally, your therapist may vacation periodically and be unavailable by phone, , or for voice messages during that time. A designated therapist will be made available for any clients who require assistance during the vacation period. It will be the client s responsibility to return a signed release of records by a pre-determined date for the designated therapist to be available to them. Please note that weather closings will occur if your therapist believes it would be unsafe for travel to and from our location. Every effort will be made to contact you should the office be closed.

7 For Life Threatening Emergencies Call 911 First Our phones are answered during regular business hours; after hours you will be directed to the clinic's voice mail. Remember if you are calling with an emergency, please hang up dial 911 or go to the closest hospital emergency room. If it is a non-emergency after business hours and your therapist is unavailable, you may call the following crisis centers: United Way 211 (first call for help) Crisis Connection Questions/Complaints Please feel free to ask questions about any techniques used during therapy. Your therapist would be happy to explain theoretical approaches and methods to you. You can request information from your therapist about assessment, treatment planning, records or other services needed. If you have a complaint of any kind about the therapy services you are receiving, your therapist is willing to collaborate with you to resolve any issues. You may discuss your concerns directly during a regular session, submit and , or mail a letter. Part of the therapeutic relationship involves working through misunderstandings and misconceptions. Every effort will be made to address your concerns. You also have the right to file a complaint with the professional organizations listed below. You have the right to end therapy at any time without any moral, legal or financial obligations (other than financial responsibility already accrued). If you decide to discontinue therapy for any reason, please notify your therapist. If requested, your therapist will provide you with the names of other qualified professionals from which to choose. A copy of the Client s Bill of Rights from the MN Board of Behavioral Health and Therapy is included below for your review. Grievance Procedures for Professional Services Minnesota Board of Behavioral Health and Therapy 2829 University Ave. SE #210 Minneapolis, MN Please note a copy of this document will be provided to you at your request

8 Consumers of therapy services offered by LMFT s, LPC s, LPCC s and LP s licensed by the State of Minnesota have the right: to expect that a therapist has met the minimal qualifications of training and experience required by state law; to examine public records maintained by the Minnesota Board of Behavioral Health and Therapy which contain the credentials of a therapist; to obtain a copy of the code of ethics from the State Register and Public Documents Division, Department of Administration, 117 University Avenue, Saint Paul, MN 55155; to report complaints to the Minnesota Board of Behavioral Health and Therapy University Park Plaza Building, 2829 University Avenue SE, Suite 210, Minneapolis, MN ; to be informed of the cost of professional services before receiving the services; to privacy as defined by rule and law; to be free from being the object of discrimination on the basis of race, religion, gender, or other unlawful category while receiving services; to have access to their records as provided in Minnesota Statutes, section ; to be free from exploitation for the benefit or advantage of a therapist. to give informed consent to make independent decisions to receive prompt and reasonable responses to questions to refuse to disclose information, although this refusal may compromise the benefits of therapy to terminate therapy to know about the process of therapy Client Responsibilities to ask questions for clarification and to correct misunderstandings to express concerns to be honest with the therapist to be respectful to the therapist s person and property to actively work and invest effort during and between therapy sessions to make full and timely payments to come to appointments on time and as scheduled to give 24 hours notice of cancellation of appointments

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