PROFESSIONAL DISCLOSURE STATEMENT AND INFORMED CONSENT

Transcription

1 Qualifications and Experience Jamie L. Jones 4707 Connecticut Avenue, NW Suite 103 Washington, DC Professional Disclosure Statement and Informed Consent Page 1 of 5 PROFESSIONAL DISCLOSURE STATEMENT AND INFORMED CONSENT Jamie L. Jones has over ten years of experience working with individuals, groups, and families in hospital, outpatient, and school settings. She currently provides client- centered, holistic and spiritually focused psychotherapy services in private practice and as a volunteer for Rock Recovery. Additionally, she has specialized training in Cognitive Behavioral Therapy and Dialectical Behavioral Therapy for the treatment of eating disorders, self- harming and addictive behavior. Jamie is most knowledgeable and gifted in her work with adolescents and adults who have a history of disordered eating, trauma, and abuse. She believes in the power of culturally sensitive, supportive, and ethical relationships, which foster the growth of self- esteem, identity development, and creativity. Jamie is a Licensed Professional Counselor PRC14344 and Board Certified Art Therapist Jamie has earned a master s degree in art therapy from The George Washington University and a bachelor s degree in psychology from Marymount University. Psychotherapy & Art Therapy Approach and Client/Therapist Roles Jamie L. Jones provides individual, group, and supervision art therapy and psychotherapy services to clients across the life span. I integrate techniques from various therapies. I work from a person- centered, strengths- based, mindfulness approach to collaborate with clients to cultivate skills and resources, expand views of a situation, and help you to find ways to live the life you want. We will explore your inner and outer experiences, relationships, images, and dreams and work toward your goals. My role is to listen in a non- judgmental way, be a guide in the art making process, ask questions, and provide feedback. You are the expert on your life. With the support of psychotherapy and art therapy, you will have new opportunities to stretch yourself in new ways to live your life. If your child or adolescent is in therapy with me, I work from the framework that the parent or primary caregiver is the primary healing agent for their young person. I will work closely with you and your child to implement relational and everyday living strategies to support your young person to work towards thriving in the home, school and the community. Risks and Benefits of Psychotherapy & Art Therapy Therapy can sometimes feel nonlinear and unpredictable, but this work is one of the best ways to clear out and heal old wounds and get to know yourself in a more meaningful and authentic way to live more fully. The goals, areas, concerns, and problems you choose to address in therapy will often dictate the amount of time spent in therapy. Some can be addressed in only a few sessions, whereas others require longer commitment. You may come to therapy to focus on one issue, resolve it, and decide to stop therapy, or you may want to explore deeper parts of yourself. It is also not uncommon to focus on a chunk of work

2 Professional Disclosure Statement and Informed Consent Page 2 of 5 that leads to a year or more commitment. You may find comfort in being at the same time and place weekly to do this important work. I look forward to collaborating on this journey with you. At any time, you may ask questions about the process or end psychotherapy and art therapy. Please keep in mind that the best endings are co- created. If you have been participating in long term or deep work, a planned ending will give you the opportunity to experience transitions or closure in a new way. Possible risks of therapy During the course of therapy, some people may have emotional responses and reactions that are unfamiliar and may be difficult to experience. The emotional discomfort that may be caused by therapy is usually temporary and will ultimately diminish in time. There is no guarantee as to the outcome of therapy and some people may even experience no improvement or even think things are worse. Possible benefits of therapy Develop balance, harmony and joy in your life. Develop understanding about yourself and make changes to create the life you want Develop healthy interactions with others and enjoy more satisfying relationships Resolve conflicts in personal relationships Learn new skills to combat depression, anxiety and stress Develop understanding and acceptance of yourself Develop better communication skills Develop better parenting skills Learn to manage your emotions, including anger, sadness and worry Feel good about yourself and your accomplishments Adjust to life transitions more easily Live a more wholehearted life with courage, compassion and connection Ethics, Competency & Obligations As a licensed and credentialed mental health professional, I am obligated by the ethical codes and laws relevant to counseling and art therapy. Part of my ethical obligation is to only provide services to clients who I am competent to serve. If I determine that your needs are outside of my expertise or scope of practice, or at your request, I can make referrals to other mental health providers. All counseling comes to an end at some point, which is called termination. We will work together to find appropriate services to meet your needs. See ethical codes at Dual Relationships Jamie L. Jones will not enter into personal (dual) relationships with clients outside of professional psychotherapy services. This boundary continues even after counseling is terminated. This is an ethical obligation that benefits you by allowing me to serve as a therapist rather than a friend. I do not initiate contact with clients in public places or communicate online or through social networking sites to protect this boundary and your confidentiality. Occasionally, I may share some of my experiences in sessions when it may be beneficial, but our focus will be on your experiences. Confidentiality Information discussed in our counseling sessions will remain confidential, except in the circumstances below or any that are mandated by law or by the ethical guidelines of the Washington, DC Board of

3 Professional Disclosure Statement and Informed Consent Page 3 of 5 Licensed Professional Counselors, the American Counseling Association, and the American Art Therapy Association. I may break confidentiality in the following instances: 1. If you make written request for the release of information. Also, if you request for diagnosis information (if applicable) to be released on a receipt for payment purposes to an insurance company. 2. if there is risk of serious or foreseeable harm to any person (yourself or another person). 3. if you disclose a life- threatening, communicable disease, I may be obligated to alert an at- risk third party. 4. if I have reason to suspect that a minor- aged, developmentally disabled, or an elderly person is in danger of being abused or neglected. I am legally obligated to report this. 5. if I am ordered to release confidential information by a court of law. 6. if I need to share information with my supervisor, with another professional for consultation, with a health care provider treating you in an emergency, or with other mental health professionals when necessary to coordinate your care. These professionals are also obligated to maintain confidentiality. Payment, Cancellations & Fee Increases Individual sessions are 50 minutes. Jamie L. Jones does not bill insurance; rather the practice is operated on a self- pay basis, payable by check to Jamie Jones, cash, or credit card. Payment is due in full at the beginning of session. Your fee is _$ per (50) minute session, payable each session and beginning at your first appointment. A $30.00 returned- check fee will be assessed. At times, longer individual sessions may be booked at 90 minutes at the rate of 1.5 x regular session rate. All regularly scheduled sessions are your financial responsibility. Jamie L. Jones reserves the right to charge 1.5% monthly interest on any outstanding balance beyond 30 days. Except in cases of emergency or serious/contagious illness, Jamie L. Jones requires a 24 hour cancellation telephone call to not charge you the full fee for the missed session. No texts and s for cancellations. Please note that your cancellation fee will be directly charged to the credit card Jamie L. Jones will have on file for you unless we have made other arrangements. (See Credit Card Authorization Form). Please note Jamie L. Jones will give each client one freebie for one emergency with less than a 24- hour notice. Jamie L. Jones will make reasonable efforts to reschedule sessions that are cancelled in a timely manner. If we are able to reschedule your appointment within the same week, we will not charge your credit card. Because therapy is a voluntary process, if you repeatedly miss or cancel appointments, I may terminate services. During the course of treatment, it may become necessary to increase fees. Fees will be reviewed periodically and will be increased no more than once during any calendar year. You will always be notified, in writing, at least 30 days prior to any change in fees. Telephone Sessions & Telephone conversations between us, for any reason, in excess of (15) minutes per day may be billed proportional to your hourly fee. Authorized telephone consultation(s) by you with anyone concerning your therapy will be billed to you proportionally at $135.00/ hr. This service is generally not covered by insurance. Appearing at meeting(s) on your behalf is not covered by insurance, and is billable to you at $135.00/hr. for the entire time spent away from the office. It is important to remember that e- mail communication is not confidential: it has the potential to be saved on servers and in computer hard- drives. However, it is very convenient to use e- mail to change or

4 Professional Disclosure Statement and Informed Consent Page 4 of 5 coordinate an appointment. We will use this method if a phone call is not possible. However, a phone call is required to cancel an appointment (See Cancelations Section above). If a client does not want to have e- mail communication, it is up to the client to inform us of this request. In general, it is not my practice to use e- mail as a form of communication for therapy. I will accept e- mails from client s in- between sessions, as long as they do not take more than a few minutes to read. The typical e- mails might be related to a child s academic or behavioral progress or from other professionals involved in treatment coordination with the client. If a client is using too much e- mail or is using it instead of working in therapy, then a discussion will take place to discuss the use of e- mails and ways to limit their use and/or to have a separate payment agreement for e- mail communication. Complaints There are no guarantees that counseling will help you achieve your goals; therefore, Jamie L. Jones cannot provide any guarantees. If you have any problems with your therapy services or ethics, please talk with Jamie (i.e., your therapist) about it. Jamie L. Jones strives to provide the best services she can, and she wants to make changes if you are not satisfied. You may also contact or file a complaint with the Washington, DC Board of Professional Counseling, 899 North Capital Street, NE, First Floor, Washington, DC (877) , Emergencies In the event of an emergency, please dial 911 or go to the emergency room immediately. As a private practitioner, Jamie L. Jones is not on call or available 24 hours a day. Often, she is with clients or away from the phone. She will generally try to return messages within 24 hours or the next business day except on holidays/vacations. If you need a higher level of services than Jamie L. Jones is able to provide as a private practitioner, we can offer a referral to a more appropriate provider. Emergency Contact Information If there is an emergency during the time we are working together, or Jamie L. Jones becomes concerned about your personal safety, she is required by law and the ethics of the profession is to contact someone close to you. Jamie may also be required to contact this person, and/or the authorities, if we become concerned about your harming someone else. By initialing here, I authorize Jamie L. Jones to contact my designated emergency contact person in the event of an emergency or if she suspects threat of harm to self or others. Please write the name and contact information of your chosen contact person in the space provided below: Emergency Contact Name: Address: Phone: Relationship to you:

5 Professional Disclosure Statement and Informed Consent Page 5 of 5 Request for Services I understand I may ask questions about this disclosure and the therapy process at any time. I may also discontinue services at any time. By signing below, I acknowledge I have read and understand this disclosure, and I am requesting counseling services from Jamie L. Jones. Client Signature Therapist Signature Date Date Please sign both copies of this statement. You will keep one for your records, and one will be kept one for the electronic records.