Counseling Services Information & Informed Consent for Professional Services
Who We Are:
The
Service Policy
General Information
Weekday appointments are available at a variety of times, including mornings, afternoons, and evenings. Sunday afternoon appointments are available with some counselors. Early in counseling, it is suggested that appointments be set up on a weekly or bi-weekly basis. Individual appointments with members of the opposite sex are scheduled before 5:00 pm Monday thru Thursday or at other times when other staff members are present. Individual and marriage counseling sessions are time for you to focus on uninterrupted communication with your counselor and/or spouse. Because it is difficult, if not impossible to avoid distractions when children are present, please make arrangements for children to be left at home with an appropriate caretaker. When children are coming for counseling, an adult needs to be on the premises during the entire counseling session.
Counseling Fee and Payment Policies
Counseling sessions for couples and individuals are 50 minutes in length. Since operating costs of our Center are partially subsidized by
Cancellation and Contact Information
Should you need to contact your counselor, our answering system will receive your call 7 days a week, 24 hours a day. When calling, please leave your name and telephone number on your counselor’s voicemail and your counselor will return your call as soon as possible. When cancellation of a counseling session is unavoidable, it is important for the client to notify the counselor 24 hours in advance. When meeting with a member of the counseling center staff, there is a $15.00 rescheduling fee for appointments cancelled on the day of the appointment. No-shows are billed at the full session rate. Consistently missed appointments (barring bona fide emergencies) or failure to complete counseling homework assignments on a regular basis may result in the termination of the counseling relationship. If your counselor must cancel an appointment, efforts will be made to notify you as soon as possible through the method indicated on the intake form. In the event of a counseling related emergency, see the following section “Emergency Information”.
Emergency Information:
In the event of an emergency situation (i.e., situations where someone is out of control, has ideas or plans of self harm or of harming others, or demonstrates potentially harmful behavior) the client should dial 911, the Crisis Hotline at 817-335-3022, or go directly to the nearest hospital emergency room to receive emergency assistance.
What if I have a complaint during the counseling process?
Whenever possible, first address concerns with your counselor. If the issue is unresolved, you may contact the center director. Concerns or complaints about a Licensed Professional Counselor that are not addressed to your satisfaction may be addressed to: Complaints Management and Investigative Section,
Informed Consent for Counseling Services
Limitations and Potential Risks Associated with Counseling
Counseling may involve discussing relational, spiritual, psychological, and/or emotional issues that at times may be distressing. There are no guaranteed outcomes as a result of participating in upcoming counseling sessions. At any point during the counseling relationship, your counselor may deem it to be in your best interests to be referred to another professional. You may discontinue counseling at any time. However, this is best accomplished in consultation with your counselor to determine if you have adequately met your goals for counseling.
Confidentiality Policy
All therapeutic communications, records, and contacts with professional and support staff will be held in strict confidence. Information may be released to appropriate third parties when you sign a written release of information indicating informed consent to such release or when
Listed below are the exceptions to confidentiality:
- The therapist makes an assessment of an impending suicide risk. (Chapter 611, Family Code)
- A client reports past or present instances of the abuse or neglect of a child, elderly person, or mentally challenged person. (Chapter 261, Family Code)
- A client acknowledges committing abuse or neglect of a child, elderly person, or mentally challenged person either in present or in the past. (Chapter 261, Family Code)
- There is a probability of imminent harm to the client or others. (Chapter 611, Sec. 004(a)(2) Health and Safety Code)
- Counseling records may be released when they are subpoenaed by a court of law.
It is our policy to assert privileged communication your right to withhold disclosure of private counseling information) in the event of #5. Although we cannot guarantee it, we will endeavor to apprise the client of all mandated disclosure. In order to provide quality care, your counselor may consult with other licensed mental health professionals. Every effort will be made to protect client identity. If you are seeing an LPC Intern or graduate level intern, they will be working under the supervision of a licensed counselor who will know something about your case. Otherwise, information about your counseling (even the fact that you are attending counseling) cannot be disclosed to other people without your permission. Your counselor will never embarrass you by initiating conversations related to counseling issues in church or other social settings.
Statement of Understanding
I hereby voluntarily apply for and consent to professional services provided by the
Client Printed Name: _______________________________________________________
Client Signature: _________________________________ Date: _______________
Parent/Guardian Name: ___________________________ (if client is a minor)
Parent/Guardian Signature: ________________________ Date:________________
Promises Counseling Center
121 SW. Haskew St., P.O. Box 279
BurlesonTX 76097
Phone: 817-295-9384
Fax: 817-295-2718
Burleson
If you would like a record of this information, please photocopy before returning.
