DISCLOSURES AND INFORMED CONSENT

Transcription

1 CATHY NEVILLE, LPC, NCC 8207 Callaghan Road, Suite 220 San Antonio, Texas Telephone: Fax: DISCLOSURES AND INFORMED CONSENT Welcome to counseling! You have taken the important first step to pursue counseling. I realize that starting counseling is a major decision, and you may have many questions. This document contains valuable information about my professional services and your rights as a client. About Counseling Counseling is most effective when approached as a collaborative effort between counselor and client. At times, the process of counseling may be difficult. Working toward positive change often requires you to step out of your comfort zone and take some risks. As your counselor, I will be there to support your journey of healing and growth. There may be times when I will suggest homework assignments between sessions. Such exercises are designed to make the counseling process more effective. About Me I am a Licensed Professional Counselor, holding license number I earned my Bachelor of Arts degree in Psychology from the University of the Incarnate Word in San Antonio, Texas. I earned my Master of Arts degree in Counseling from the University of Texas at San Antonio. Disclaimer I am licensed as a professional counselor, not as a physician, psychologist or psychiatrist. I cannot and will not diagnose, treat, cure, mitigate or prevent any medical or psychological disease, disorder or condition. If I find you need such services, I will be happy to provide you with referrals in order to meet those needs. Therapeutic Approach There are several theories with which therapists/counselors use to approach counseling with their clients. The approach I use with my client will depend on his/her personality and individual situation. My favorite and most- often used treatment orientations are evidence- based, such as Solution- Focused Brief Therapy, Cognitive Behavioral Therapy, Existential Therapy, Humanistic Therapy, Feminist Therapy, Emotionally- Focused Therapy, and Positive Psychology. My approach emphasizes the importance of the therapeutic relationship, as well as the client- as- expert perspective. I aim to empower clients in the context of their social and cultural environments, and I draw heavily from positive psychology and strengths-

2 based counseling by nurturing the resilience in each of us. Appointments Counseling is by appointment only. In the event you need to cancel or reschedule an appointment, please call, or text me with a 24- hour notice. Failure to do so will result in being billed for the missed appointment. Ending Therapy You are free to stop counseling at any time. If you or I believe that progress is not being made, either of us may talk about ending counseling. My priority is that you are able to make the necessary changes to fulfill your goals for counseling. Fees My fee schedule is as follows: $ per 60- minute session of individual counseling/psychotherapy $ per 75- minute session of couples counseling/coaching All payments are due prior to your session. I accept cash, checks or credit card. I accept the following insurance: 1) Multiplan 2) American Behavioral 3) Blue Cross Blue Shield 4) Aetna 5) Humana 6) MHN 7) Tricare Hours I am available for appointments during the hours of 9 a.m. to 6 p.m., Monday through Friday, by appointment only. I am available for some Saturday appointments from 9 a.m. to 1 p.m., if necessary. Emergencies In the case of an emergency or psychological crisis after business hours, (i.e. any threats of harm to self or others), please call 911. If you have experienced serious harm, go immediately to the nearest emergency room. Of course, I would encourage my clients to make an appointment following such a crisis in order that we may process together what you are now (or have been) experiencing Confidentiality I understand that Texas state law requires that information provided to mental

3 health practitioners remain confidential and I make every effort to ensure confidentiality is maintained with respect to all aspects of your treatment. As my client, you agree to the following exceptions to confidentiality, in which case may be disclosed to the appropriate authorities/agencies/individuals: If I, your therapist, have reason to believe that you may harm yourself or others. If I, your therapist, have reason to believe that you are involved in or have knowledge of abuse or neglect of a child; or abuse, neglect, or exploitation of a person who is elderly or has a disability. Ordered disclosure by state or federal courts. In addition, we require disclosure of information in the following circumstances: A signed release form granting permission to designated third parties to receive information (as needed) I understand and accept the above- stated limits to confidentiality concerning counseling. Client s Signature Date Consent for Counseling I have read, understood, and agree to the terms of this consent. (If you have any questions, please ask before you sign). By signing, I voluntarily agree to participate in counseling. Client s Signature Date

4 INSURANCE CLIENTS ONLY Insurance Information: (only clients wishing to use their insurance need to fill this page out) All clients wishing to use their medical (health) insurance to pay for mental health services need to understand the following: I am required to provide the insurance company with a mental health diagnosis from the Diagnostics and Statistical Manual of Mental Disorders. The diagnosis and treatment will become part of your permanent insurance record. If you do not have a legitimate mental health diagnosis such as depression, anxiety, mood disorder etc. then you cannot use insurance to pay for your sessions with me. Additionally, seriously consider the following before deciding you want to use your insurance for psychotherapy or counseling: 1. Insurance company representatives can call asking for your personal treatment information to justify continuing to pay for services. I am required to answer all of their questions if you want to continue to have them pay for your sessions. 2. Having a mental health diagnosis on your insurance record can have a future negative effect on you in any of the following ways: a. You apply for life insurance increased rates or refusal to insure you b. Disability insurance increased rates or refusal to insure you c. Government Security clearance If you have a security clearance you do not want a mental health diagnosis on your record d. Child custody hearings A mental health diagnosis can be used against you e. Job loss if an employer believes your mental health diagnosis may impact your ability to do your work. f. Loss of right to control your own legal and medical affairs if you are deemed incompetent g. While your records are considered confidential, insurance companies do share these records, at least in aggregate form, with each other. In addition, these large databases may be accessed by others such as insurance companies bidding for employer- sponsored group health plans. If you are uncomfortable with this possibility then you should not use your health insurance to pay for counseling.

5 Couples Therapy: Medical insurance companies (this does not include EAP benefits) do not reimburse for "relationship issues." They do not consider it medically necessary and any claim sent to them with a diagnosis of relationship issues is rejected. It's a violation of my contract to bill the insurance company for relationship counseling under the guise of mental illness treatment. Additionally, the conditions spelled out in the first section above apply here as well. Fee for Service: All co- pay and co- insurance is due at the beginning of each session. You are responsible for any balance due that the insurance company does not pay based on their negotiated rate with me. In this case you can pay me at the time I present you with a statement or I can charge the credit card you have put on file. Charge for a missed session is $80.00 (insurance will not pay for missed sessions) Insurance Information: Primary Insured's Name: Primary Insured's birthdate: / / Primary Insured's SSN: Zip Code: - - You'll need to bring your insurance card to the first appointment Your signature below authorizes me to bill your insurance company and disclose any confidential information requested to them. I have read this, have had all my questions answered to my satisfaction. I understand and consent: Printed name (1st individual) Signature Date Signed