Please read our policies and information about Texas State Statues in relation to treating minor children.

INFORMED CONSENT

General Information The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of these with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process: You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I promise to support you and do my very best to understand you and repeat patterns, as well as to help you clarify what it is that you want for yourself. The success of treatment increases on my adherence to agreed-upon treatment plan goals and regular attendance to sessions.

Confidentiality

NO RECORDING OF ANY PART OF SESSION VIA ANY ELECTRONIC MEANS IS ALLOWED WITHOUT THE EXPRESSED CONSENT OF BOTH PARTIES. Failure to comply with this standard will result in treatment termination. The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all/or portions of such content released to a specifically named person/s. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a way there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above are in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by the order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

I understand my counselor can only have a therapeutic, professional relationship with me. It would be inappropriate to have a social, personal or business relationship, to exchange or bestow gifts, spend time with each other socially, or attend family functions or religious ceremonies.

If we see each other outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Confidentiality with Minors

Therapy is most effective when a trusting relationship exists between the counselor and the client. Privacy is important in securing and maintaining that trust. Specific details of the information children share with their clinician in session is not shared with parent/caregiver (unless the child gives his/her/their consent) so as to encourage children to be honest and forthcoming and to maintain an emotionally safe environment for them. Your clinician will speak with you in a general way unless there is a danger to the child’s life. They will provide you with summaries of treatment goals, plans, progress and recommendations. As part of the therapeutic process, we encourage children to share information with their parents. Sometimes we ask the child and parent to meet with me so that the parent can voice concerns or ask questions. However, there are specific exceptions to this confidentiality which include the following: LIMITATIONS TO CONFIDENTIALITY

1. When there is a risk of imminent danger to your child or another person, Texas State Law requires any therapist to notify the legal authorities. This includes providing information that indicates there is reason to believe that a client is being abused, a client poses a risk to others, or a client poses a risk to themselves. Additionally, if there is suspicion that your child is being sexually or physically abused or is at risk of abuse, I am mandated to take steps to protect your child and to inform the proper authorities.

2. If a client reveals to the therapist any evidence of professional misconduct (e.g., sexual involvement) perpetrated by a previous clinical provider, the current therapist is required to report this information to the state licensing board.

3. If your records are court ordered to be released by a judge, I am required by law to release the records to that judge for review. Failure of the treating clinician to report in circumstances 1 or 2 mentioned above is a breach of legal and ethical standards, which can lead to prosecution, and/or loss of licensure. Please understand that all records, written information, or any electronic data are marked CONFIDENTIAL and are kept under lock and key. Your confidentiality is very important to us. To ensure the quality of care and provide comprehensive, wrap around support, we may consult with other providers within our group practice as needed. All information shared within our practice remains strictly confidential and is used solely to enhance your therapeutic experience. No personal health information will be shared in consultation. Information shared with a therapist is held in confidence. A signed and dated Release of Information (which clearly defines the nature of information to be shared, to whom and for how long) is required as consent to disclose confidential information. If the client is a minor, the release must be completed, signed, and dated by a parent or legal guardian.

Confidential or sensitive information is not appropriate conversation for the waiting room/lobby. If you would like to discuss your child’s therapy services or progress, please schedule a parent consultation.

Consulting

Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name.

Referrals

If your diagnosis or treatment needs can be best served by another provider with expertise in that area, I can recommend a referral to a psychiatrist, behavioral center, or other mental health provider.

Counselor Incapacity or death

In the event of counselor incapacity/death, I agree my case may be transferred to another therapist or referred to my Primary Care Physician. I have the right to choose a provider, and consent for my records to be released.

Minors

If you are a minor, your parents may be legally entitled to some information about your therapy. We will discuss with you and your parent/s what information is appropriate for them to receive, and which issues are more appropriately kept confidential.

According to Texas Administrative RULE §681.35: “Prior to the commencement of counseling services to a minor client who is named in a custody agreement or court order, a licensee must obtain and review a current copy of the custody agreement or court order, as well as any applicable part of the divorce decree. A licensee must maintain these documents in the client’s record and always abide by the documents.”

Use of Touch

Touch is considered essential to human experience and is a powerful form of communication. Touch, when used appropriately, can promote growth and provide healing. When misused, it can impede healthy development and cause harm. Touch can be a triggering word and/or action for some individuals who have experienced certain trauma types, such as physical or sexual abuse. On a case-by-case basis, your clinician may incorporate ethical, appropriate touch as part of the therapy process. Your clinician will ask your permission whenever possible before touching someone and you and your child have the right to decline or refuse to be touched without any fear or concern about reprisal. It might not be possible to ask you or your child’s permission in every circumstance such as but not limited to accidental touch or in self-defense.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after an appropriate discussion with you and a termination process if we determine that the psychotherapy is not effectively used or if you are in default on payment. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for FOUR consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we consider the professional relationship TERMINATED.

A therapist cannot date a client nor have a personal relationship with a client. Should the lack of boundaries be an issue, we will transfer services at our discretion as per the Ethic’s Code.

Client rights

➢ I have the rights guaranteed by Texas and the United Stated Law. ➢ I have the right to release my information with a signed Release of Confidential Information Form. ➢ I have the right to be treated with respect and dignity and recognition for my need for privacy. ➢ I have the right to complain about my provider. I may contact: Complaints Management and Investigative Section P.O. Bo 141369 Austin, TX. 78714-1369 1-800-942-5540

Records

Records will be destroyed seven years from my last session (adult or children). I am aware that there is a fee if I request copies of my records. Please allow up to 15 business days for records. There is a fee for records release ($50).

Insurance

I authorize Minds in Action, Inc. or its representatives to communicate with my Health Insurance for myself or dependent. I authorize the release of billing information needed for reimbursement purposes.

PRACTICE POLICIES

Appointments and cancellations

Please remember to cancel or reschedule 24 hours in advance. There is a $65 fee if cancellation is less than 24 hours.

Therapy sessions are 50-55 minutes in length.

A NO-SHOW to a scheduled session will incur a $65 fee. The session time is held exclusively for you and cannot be filled with by other clients on short notice. If you are late for your scheduled appointment, it may shorten your session time.

Accessibility

Please use Client Portal to contact us, it’s the most private and secure method, the link is in the website for ease of use. If you need to contact our therapists between sessions, please leave a message on voice mail. We may not be immediately available; however, we will return your call within 24 hours approximately.

Social media

For confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any personal social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

If you follow any of our social media accounts, and you decide to comment or share, forward, re-post, you are thus agreeing you are solely responsible for any loss of confidentiality.

Electronic communication

We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. We try to return messages in a timely manner but cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or emergencies (for that please call 911). Client portal is highly encouraged for confidentiality purposes.

Email Notices

You will be added to our newsletter email list. We find this method of communication to inform clients of upcoming seminars, groups, services, insurance updates, new therapists and such. However, if you wish to un-subscribe you will be able to do so on any email you receive, and your email will be deleted from our list.

View our rates HERE

Court Action and Legal Fees

Clients are discouraged from having their clinician subpoenaed or having him/her/them provide records for the purpose of litigation. Even though you are responsible for the testimony fee, it does not mean that our testimony will be solely in your favor. Your clinician can only testify to the facts of the case, and, if qualified to do so by the court, their professional opinion within the scope of their practice. If you choose to subpoena your clinician to testify or provide records in a case where the client is a child, the therapeutic relationship is effectively ended, and they may not continue to provide services to that child/family.

If your clinician is to receive a subpoena, then the attorney or office staff will need to call our office and set up a time for the subpoena to be served during office hours. We request a minimum of 72-business-hours’ notice of any Court appearance so that schedule changes for their clients can be made within a reasonable time frame.

Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72-business-hours’ notice, there will be an additional $250 express charge.

• Preparation time (including but not limited to submission of records, consultations and emails): $250/hr (billable in 15-minute increments)

• Phone calls: $250/hr (billable in 15-minute increments)

• Filing a document with the court: $250

• All attorney fees and costs incurred by the therapist because of legal action.

A retainer of $700 is due on the date our office accepts the subpoena. The remainder of the costs will be billed after the court’s appearance and due upon receipt. If the therapist is subpoenaed and the case is reset with less than 72 business hours’ notice prior to the beginning of the day of the scheduled trial, subpoena, and/or testimony, then the client will be charged $500 (in addition to the original $700 retainer for having to appear in court). All fees listed are doubled if the therapist has been scheduled to be out of town at the time of the court appearance.

Litigation, Divorce, and Custody Cases

When a family is confronted by caregiver separation or divorce, it is very difficult for everyone, especially children. When the caregiver relationship is conflictual, it is even more important that therapy presents an emotionally safe environment. Minds in Action Counseling wish to be clear about our position when parents are separated, pending separation, divorced, or engaged in litigation. Our primary therapeutic goal is to provide consistent and stable care before, during, and after this process with your child and your family. We need your agreement that our involvement will be strictly limited to therapy or evaluations that will benefit your child. We do not provide forensic or custody evaluations. If a therapist is subpoenaed regarding custody or divorce disputes, they will not be able to continue as your child or family’s therapist. Each caregiver must consent to these policies.

Importance of Therapy Confidentiality

If information discussed between the child and therapist is revealed to either parent without the child’s consent, then potential emotional harm can occur. Children and adolescents do better if they are able to have a place where they can feel that they are not in the middle of conflict and do not need to take sides. Effectiveness of treatment is compromised if children feel as if they must be messengers, reporters, or allies for either parent.

As parents, you can provide the therapist with information of relevance for your child’s well-being. The therapist will keep all information learned from and about the child confidential, although the parents may be given a broad overview of concerns and updates about treatment. If the child agrees that information is to be shared with parents, then specific disclosures will be made available to the parents. If the information involves abuse, neglect, or safety issues, confidentiality is waived. If the therapist believes that a child is a serious risk or harm to himself or others, the therapist may breach the child’s confidentiality. It is understood that the therapist will encourage and assist children in sharing information with parents when appropriate. The therapist will use informed clinical judgment about what must be shared and about the most effective method of transferring information to parents.

Court Involvement

To protect the child’s confidentiality and the effectiveness of treatment, it must be agreed upon that the therapist will not be called as a witness in a court proceeding by either party. As referenced within the confidentiality section above, revealing information discussed between the child and the therapist can have potentially emotionally damaging effects on the child, the family, and the entire treatment process.

Therapists do not notify or write letters about custody or visitation arrangements. Our therapists do not usually participate in court proceedings; however, a judge may require that the therapist be a witness. If a therapist is mandated by the court to testify, parents must pay the fees as outlined in our Court/Legal Fees Agreement section above and all associated costs. Although our responsibility to your child may require our involvement in conflicts between both parents, we need your agreement that our involvement will be strictly limited to that which will benefit your child. This means, among other things, that the therapist will treat anything that is said in session with us as confidential. Neither parent will attempt to gain advantage in any legal proceeding between the two of you from our involvement with your children. Our therapists need your agreement that in any such proceedings, neither parent will ask us to testify in court, whether in person, or by affidavit. Each parent also agrees to instruct your attorneys not to subpoena us or to refer to any court filing to anything we have said or done. If a therapist is subpoenaed regarding custody or divorce disputes, they will not be able to continue as your child or family’s therapist.

Note that such an agreement may not prevent a judge from requiring the therapist’s testimony. If required to testify, the therapist is ethically bound not to give an opinion about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, the therapist will provide information as needed (if appropriate releases are signed or a court order is provided) but will not make any recommendation about the final decision. Furthermore, if a therapist is required to appear as a witness, the party responsible for our participation agrees to reimburse us at the rates noted in our Court/Legal Fees Agreement Form for time spent traveling, preparing reports, testifying, being in attendance, and any other case related costs. If the party who subpoenaed the therapist was not a party to this contract, then the party or parties who signed the contract are obligated to reimburse the therapist costs for involvement on behalf of your family.

Texas Administrative Code for LPC-S/LPC/LPC Associate:

Title 22, Part 30, Chapter 681, Subchapter N:

(a) Licensees must comply with Texas Family Code, Chapter 107, Sub-chapters D, E, and F concerning Child Custody Evaluation, Adoption Evaluation, and Evaluations in Contested Adoptions.

(b) A licensee who has completed a doctoral degree and at least 10 court-ordered child custody evaluations under the supervision of an individual qualified by the Texas Family Code, Chapter 107 to perform child custody evaluations is qualified to conduct child custody evaluations under Texas Family Code, Chapter 107. All other licenses must comply with qualifications stipulated in the Texas Family Code, Chapter 107.

(c) Any complaint relating to the outcome of a child custody evaluation or adoption evaluation conducted by a licensee must be reported to the court that ordered the evaluation, see Council §884.3.

(d) Disclosure of confidential information in violation of Texas Family Code, §107.111 or §107.163 is grounds for disciplinary action, up to and including revocation of license, by the council.

(e) A licensee who provides services concerning a matter which the licensee knows or should know will be utilized in a legal proceeding, such as a divorce, child custody determination, disability claim, or criminal prosecution, must comply with all applicable board rules in this chapter regardless of whether the licensee is acting as a factual witness or an expert.

(f) A licensee may not provide therapy and any other type of service, including but not limited to a child custody evaluation or parenting facilitation, in the same case, whether such services are delivered sequentially or simultaneously.

(g) Licensees may not offer an expert opinion or recommendation relating to the conservatorship of or possession of or access to a child unless the licensee has conducted a child custody evaluation relating to the child under Texas Family Code, Subchapter D, Chapter 107.

(h) Licensees providing child custody evaluations or adoption evaluations must, prior to beginning the evaluation, in writing inform the parties of: (1) The limitations on confidentiality in the evaluation process; and (2) The basis of fees and costs and the method of payment, including any fees associated with postponement, cancelation and/or nonappearance, and the parties’ pro rata share of the fees and costs as determined by the court order or written agreement of the parties.

(i) A Licensed Professional Counselor Associate (LPC Associate) must not conduct child custody evaluations or adoption evaluations unless qualified by another professional license to provide such services.

Agreements:

I understand that the evaluation and/or treatment of my child is intended solely to provide treatment to address their psychological needs.

I understand that the usual exceptions to confidentiality apply as stated above and in our Consent to Psychotherapy Services.

I understand that the treating therapist is not part of any legal proceedings unless the court ordered. This means the therapist does not write any report for either party supporting his or her position in custody or changes in visitation.

I understand that if the treating therapist is subpoenaed regarding custody or divorce disputes, they will not be able to continue as your child or family’s therapist.

We the undersigned fully understand and freely agree to these conditions regarding psychological services for our child or children, and for ourselves regarding co-parenting or parenting issues.

Divorce and Separation Cases

Due to the sensitive nature of divorce, separation and all potential issues that may arise in such cases, Minds in Action Counseling has very specific policies to which you must agree before we enter a counseling relationship.

1. If I am seeing a child whose parents are in the process of divorce or who are already divorced, I require a copy of the standing court order, mediation agreement, or other legal documentation demonstrating the custodial and consent rights of each parent and/or the parenting agreement that is signed by both parents and the judge at the first intake session. I will need to have contact with the parent who has legal custodial decision making for medical issues before I see the child for counseling and I will need to obtain written consent for the child to participate in counseling from the legal custodian(s) and prefer to have contact with both parents prior to seeing the child.

2. I will provide an identical summary of a child’s therapy progress, treatment plan information and parent recommendations to both parents who share in the legal custody of the child I am seeing for counseling, and I will offer and encourage opportunities for both parents to participate in parent consultations along the way. All emails will include both caregivers.

3. I will provide treatment that will help facilitate your child’s adjustment to separation or divorce, but I do not provide forensic interviews, custody or visitation evaluations, or release of records. I do not serve as an expert witness or provide testimonial services in custody battles.

Additional Service Rates:

$ 75 School Letter

$175 School letter w/ Diagnosis and Recommendations

$450 Reports for court, or legal matters

$ 50 Medical Records (State Law allows up to 15 business days for release)

$175 Attorney Letters

$175 Court Appearance per hour in addition to retainer

$700 Retainer if you involve counselor in court case