Play Therapy, Individual, and Group Counseling Keshia Lori Smith, M.S., LPC (469)

Transcription

1 Play Therapy, Individual, and Group Counseling Keshia Lori Smith, M.S., LPC (469) PROFESSIONAL DISCLOSURE STATEMENT Qualifications: I am a qualified Licensed Professional Counselor. My areas of expertise include working with children through areas of play therapy and with adolescents through activity therapy and individual counseling. I also work with adult individuals, couples, and families. Areas I deal with include: child behavior, depression, anxiety disorders, social skills, family and relationship issues, grief, addiction, stress management, and personal growth. I am currently working as a child and adolescent play therapist, adult counselor, and a couples and family therapist. Experience: I have earned an undergraduate degree from Texas Tech University where I majored in Human Development and Family Studies. I received a Masters of Science in Counseling at Southern Methodist University. My practicum experience included working at the SMU Center for Family Counseling with children through play therapy, adolescents, adult individuals, couples, and families. I continued on with my practicum at the Seay Behavioral Health Center, where I worked with inpatient and outpatient adolescents struggling with addiction, suicidal behaviors, depression, anxiety, and impulsive and destructive behaviors. I completed a 3,000 hour internship under the supervision of Dr. Miki Kidron. My formal education, both undergraduate and graduate, as well as my practicum and internship experience has prepared me to be a knowledgeable and effective counselor. Nature of Counseling: As human beings, we are all fallible. Sometimes striving for perfection can lead to self-blame, intolerance, and avoidance of actualizing growth potentials. As a counselor I believe in helping and guiding individuals through encouragement towards their own personal growth. Encouragement is a powerful method available for changing a person s beliefs, for it helps clients build self-confidence and stimulates courage and change. Counseling provides the opportunity for growth and self-discovery in the context of a safe, supportive, and therapeutic relationship. Together we can acknowledge, accept, recognize, and value the person that you are and the person you wish to become. Informed Consent Emergency/Crisis: Please know that I do not provide a 24-hour crisis counseling service. Should you experience an emergency necessitating immediate mental health attention, immediately call or go to an emergency room for assistance. Counseling Relationship: During the time we work together, we will meet weekly for approximately 45 minutes per session. This is the time you will be billed for. Although our session may be very intimate psychologically, we have a professional relationship rather than a social one. Our contact will be limited to counseling sessions you arrange with me except in case of an emergency when you may contact me or leave a message during business hours at (469) Please do not invite me to social gatherings, offer me gifts, ask me to write references for you, or ask me to relate to you in any way other than the professional context of our counseling sessions. You will best be served if our sessions concentrate exclusively on you or your child. Effects of Counseling: At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discounting counseling. While benefits are expected from counseling, specific results are not guaranteed. Counseling is a process of personal exploration and may lead to major changes in your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Some of these life changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achieve the best possible results for you.

2 Assessments: There are four assessments I offer (1) to help clarify or identify the problem areas more comprehensively for your child and (2) to use the assessments as a direct way of ascertaining an additional measure of progress for your child. The assessment instruments utilized are the Parenting Stress Index, the Child Behavior Checklist, and the Conner s. Both a pre-test and post-test will be administered for a fee of $ Please indicate to me early in counseling process as to your interest in receiving this assessment for your child. If your child is between the ages of 13-18, the instruments will vary to include a self-esteem assessment as well. Please note that this is an optional service, provided only to augment the counseling process. A Child Developmental Assessment may be administered for a fee of $250. This assessment is applicable for children 4-7 years of age. Play Therapy Logistics: For play therapy, sometimes it may be necessary to end the session early depending upon the following circumstances: the nature of the cleanliness of the playroom, the child s ability to leave when the session is over, a situation where play therapy could no longer continue (e.g., child gets sick, child breaks several toys, child chooses to leave and not return, etc.), and the need for a parent consultation. Because the session may need to end early at times, please be sure to remain in the waiting room for most of the session. Children in the playroom are not asked to clean the room following the session. The reason for this is as follows: If play is a child s language and toys are the child s words; having a child clean up the play room following the session would be analogous to asking the child to clean up his/her emotional world. It would be similar to having an adult take back everything he/she said at the end of the counseling session. This is a unique stipulation to play therapy please know I am not advocating this action for other circumstances only play therapy. When the child greets you in the waiting room following the counseling session, it is best not to ask several questions, such as Did you have fun? While playing is a natural, pleasurable activity for the child, children in play therapy are involved in playing out problems and emotional struggle and, therefore, at times playing may not be so enjoyable. Furthermore, when asked what the child did in play therapy, the child will typically respond, I played. This would be similar to asking an adult in counseling what he or she did in the session We talked. Before your child attends play therapy, please take him/her to the bathroom. Play therapy can often be very emotional freeing, causing the child sometimes to have to use the bathroom during therapy. It is helpful if the child goes to the restroom before the session begins. Also, if your child is coming from school and is hungry, please give him/her a snack before therapy starts. Only in rare circumstances will the food be provided for a child in play therapy. In such a situation, this will be discussed with the caregiver and added to the treatment plan. Please know that the playroom has a variety of media that can be messy (e.g., easel paints, water-color paints, Play-Doh, clay, water, sand, etc.). Please dress your child in clothes that can tolerate mess or possible stains should the child spill paint on him/her. Also, if your child is allergic to any substance that falls into this realm, it is your responsibility to let the play therapist know so that appropriate modifications can be made for your child. The play therapist will meet with you on a regular basis to give feedback on your child. While the feedback will discuss overall play themes for your child, discussion on several specific play behaviors will not be discussed to protect the child s confidentiality. However, most certainly at times, it will be necessary to discuss specific play behaviors and what this may mean for your child. To better facilitate the play therapy process, the play therapist will ask that you complete a Weekly Update Log for your child (A sheet of paper handed to you at the start of every session to address updates, concerns, or questions). Clients Rights: If a divorce has occurred, a copy of the section in the divorce decree that addresses custody is required. If joint custody exists, the parent not bringing the child will also be contacted at some point via letter with an intake form and an invitation to that parent to call with any questions. Please understand that the other parent will only be contacted to assist the therapist in the manner of working with your child. The therapist is not to provide information to the other parent regarding your child other than 2

3 under the auspice of the therapist's work with the child within the counseling session. Furthermore, it is helpful that the therapist is apprised of other existing important documentation, such as court orders, mental health evaluations, etc. Some clients need only a few counseling sessions to achieve their goals; others may require months or even years. As a client, you are in complete control and may end our counseling relationship at any time though I do ask that you participate in a termination session. You also have the right to refuse or discuss modification of any of my counseling techniques or suggestions that you believe might be harmful. I assure you that my counseling services will be rendered in a professional manner consistent with accepted legal and ethical standards as stipulated by the American Counseling Association. If at any time for any reason you are dissatisfied with my services, please let me know so that existing issues can be worked through. If I am not available to resolve your concerns, you may report your complaints to my licensing board, Licensed Professional Counseling Board of Texas. Referrals: Should you and/or I believe that a referral is needed; I will provide some alternatives, including programs and/or people who may be available to assist you. Also, should you miss two appointments concurrently for whatever reason; a referral will also be provided. You will be responsible for contacting and evaluating those referrals and/or alternatives. Fees: In return for a fee of per session, I agree to provide counseling services for you. My starting fee is $ per hour, but I do offer a sliding fee scale. However, should the fee scale still not be in the range you are able to afford for counseling at this time based on extenuating circumstances, please indicate the amount that is affordable right now so that the provision and fee of counseling services can be assessed. The sliding fee scale is based on the number of individuals in the household and annual salary. The fee for each session will be due prior to the commencement of each session. Checks are payable to, Keshia Smith. Should there be a need to pay for two sessions at once, the session balance must be paid within two weeks or you will be provided with appropriate referral information. I am not a provider of any insurance but I will provide you with a receipt that you can send your insurance company if you wish. Please note: If a cancellation occurs without 24 hour notification, a regular session fee will be billed to you. All returned checks will incur a $25.00 return-check fee. Records and Confidentiality: All of our communications become part of the clinical record. Records are the property of Keshia Smith, LPC. Adult client records are disposed of seven years after the file is closed. Guardians do have access to child-client files and will need to sign for consent of services (within joint custody cases, only one guardian is needed to sign for consent for the child). Minor client records are disposed of seven years after the client's 18th birthday. Most of our communication is confidential, but the following limitations and exceptions due exist: a) you are a danger to yourself or someone else; b) you disclose sexual contact with another mental health professional; c) I am ordered by a court to disclose information; d) You direct me to release your records; e) I am otherwise required by law to disclose information; f) I am billing a third-party for your counseling services (e.g., insurance, Medicaid, etc.) there is a reason to believe that child, elderly, or handicap abuse and/or neglect exists or a situation exists possibly leading to abuse or neglect. Should you an entity through your signature, request a copy of you or your child s counseling records, please be aware that a $25.00 record preparation fee will be incurred and a release of records form must be signed. An overall counseling summary, in lieu of records, may also be provided upon request. A fee of $180 is charged for preparation time. If records are subpoenaed, this does not indicate an automatic release of records and is at liberty to be quashed should it be deemed not in the client s best interest. To further protect your confidentiality, if I see you in public, I will only acknowledge you if you approach me first. Court: If you have a suspicion that your case will be going to court, or you will need therapist testimony, please let me know. Should you subpoena me as a factual case witness or an expert witness or involve me in any court-related process, please know that my retainer fee is $ , with an additional $ for every hour involved including case preparation, travel, witness time, and any wait time related to a court-related process. Please note: 24 hour advanced notice is required if a cancellation occurs related to a court process, including dismissal of case. If a 24 hour notification is not made, a fee of $500 will be billed. If you do issue me a subpoena without my approval, please note that your subpoena will be directly turned over to my attorney, unless I feel prudent to disclose certain confidential information on the stand that could protect a child, elder, or handicapped person. A bill will be rendered to you for immediate payment. Please let me know before establishing a counseling relationship if you are attending counseling for court or court-related purposes/motivations. Other fees: A fee of $25 per 15 minutes is assessed for all consultations whether by phone, in person, electronic communication, or otherwise, which include but are not limited to, home and family social studies, child protective 3

4 service cases, adoption and foster care, issues of divorce, child custody, attorney consultations, medical concerns, psychiatric concerns, educational concerns, and behavioral concerns. Cancellation: In the event that you will not be able to keep an appointment, please give notification within 24 hours in advance. If no 24-hour notification is made, a regular session fee will be billed to you. If you are absent two weeks in a row without contacting me, you will be provided with other referral sources for further counseling. Likewise, if you are absent three sessions in a row, even with contact, you will provided with other referral sources for a continuation of counseling at a different facility. If you do, at any time, intend to discontinue counseling, please inform me as soon as possible so that other clients can be serviced. *** By your signature below, you are indicating that you read and understood this document, or that any questions you had about this document were answered to your satisfaction- and that you were furnished a copy of this document. By my signature, I verify the accuracy of this document, issue consent for Keshia Lori Smith, M.S., LPC, to work with my child (client must sign over the age of 12), understand my financial obligations, and acknowledge my commitment to conform to its entire specifications. Client's Signature Date Keshia Lori Smith, M.S., LPC Date Updated April 2012 Client Copy Keshia Smith s copy *** By your signature below, you are indicating that you read and understood the professional disclosure statement provided to you and any questions you had about this document were answered to your satisfaction, and that you were furnished a copy of this document. By my signature, I verify the accuracy of this document, issue consent for Keshia Lori Smith, M.S., LPC, to work with my child (client must sign over the age of 12), understand my financial obligations, and acknowledge my commitment to conform to its entire specifications. Client's Signature Date

5 Keshia Lori Smith, M.S., LPC Date