Northeast Counseling Associates, LLC

							                        Northeast Counseling & Coaching
                  3 Northern Blvd. Unit 4B, Amherst, NH 03031
                                (603) 554-8193

                Notice to Clients and Informed Treatment Consent

Marci Martel, Ph.D. LCMHC

The following document explains the specifics about the professional services
offered by Northeast Counseling & Coaching. Please review the document and
feel free to ask any questions prior to your signing the consent form found at the
end of this document as it will be a binding document stating that you
understand the policies and procedures contained and consent to treatment.

License and Code of Ethics

Marci Martel is a Licensed Clinical Mental Health Counselor within the State of
New Hampshire (License #429). She subscribes to the ethical code of the
American Mental Health Counseling Association and is an active member of the
American Counseling Association and the American Mental Health Counseling
Association. The license is available for you to view if you request.

NH Mental Health Bill of Rights

A copy of the Patient Bill of Rights is displayed in the office and a copy is
available to you if you request it.

Qualifications and Scope of Practice

Marci has a Ph.D. in Psychology with a specialty in Family Psychology from
Capella University received in 2008. She received her Master of Science degree in
Community Psychology in 1998 from Springfield College. Her areas of practice
include individual, family, and couples therapy for children, adolescents, and
adults. She specializes in sexual abuse and domestic violence treatment for
women and parenting issues with young children. She is a Level II trained as an
Eye Movement Desensitization and Reprocessing (EMDR) clinician.

Psychotherapy Services

Psychotherapy is not easily described in words. The treatment plan for each
individual will vary depending on the nature of treatment and the diagnosis being
treated. I understand that there are risks and benefits to treatment and at times I
may feel worse after treatment. Treatment often leads to a significant reduction
in symptoms after a period of time. I realize that this is dependent on several
things: my relationships with my therapist, my willingness to participate actively
in therapy, the consistency of sessions, and the treatment methods being used.
However, there is no guarantee of successful resolution in therapy.
Meetings

Psychotherapy sessions are held at an agreed upon time and place. This will be
arranged between myself and my therapist. I understand that my sessions are
45-50 minutes. If at any time I feel concerned about these differences, I agree to
discuss them with my therapist.

Professional Fees

The fees for sessions are $150 for an intake and $100 per session or offered on a
sliding fee scale when necessary. I understand that if my insurance does not
cover a session, I will be responsible for the balance on my account. If for any
reason your case requires attendance in a court hearing, you are responsible for a
$200 per hour fee which includes travel time to and from court.

Billing and Payments

You are expected to pay for each session as it occurs unless you have insurance in
which the services will be billed. Missed therapy appointments or cancelled
appointments without 24 hours notice carry a missed appointment fee of $65.

Insurance Reimbursements

When insurance companies are billed it usually requires a diagnosis and a
treatment plan at some time. This means that private information is shared with
my insurance company. Insurance companies are required by law to keep this
information private, but I agree not to hold Northeast Counseling & Coaching
responsible for the sharing of this information as it is required for billing. If at
any time I have questions about what information is being shared, I understand
that I have a right to know what is being shared.

Contacting Your Therapist

If I experience a life threatening emergency, I agree to call 911 or go to a local
emergency room. Your therapist is available 24 hours a day and 7 days a week for
emergency situations. I agree that if the consultation by phone lasts longer than
10 minutes, I will be billed a $50 fee for the consultation as this is not covered by
insurance. At times it may be better to schedule an emergency consultation.

Professional Records

Records of sessions are kept to document treatment. The records are kept in a
locked cabinet and not accessible to anyone outside of Northeast Counseling &
Coaching or my insurance company. If I need a copy of my record for any reason,
I will discuss this with my therapist. It is Northeast Counseling & Coaching’s
procedure that releases of records can usually be done through a summarized
report. If I would like a copy of my records, I agree to provide, in writing, a
request for my records. I realize that this request will be processed within 2-3
weeks of my request and will require a fee for copying services of $1 per page up
to a maximum of $20.

Limits to Therapeutic Relationship

Psychotherapy is professional and voluntary service being provided to you and
requiring a relationship between a client and therapist. This relationship is a
unique and different type of relationship than most relationships. Our
relationship will be limited to client and therapist. Any other relationship would
create a “dual relationship”. Therefore, I cannot engage in a friendship, business
relationship, sexual relationship, or employer relationship. I cannot give you
legal, medical, financial, or any type of professional advice.

At times the relationship between a therapist and client may feel very “friendly”.
Friends offer advice from their own point of view and usually do this to be
helpful. A therapist will offer you choices and help you solve your own problems
based on theories and methods of change. Therapists are required to keep your
identity confidential, therefore I may ignore you in a public place unless you
initiate contact. I must decline to attend your family gatherings if invited.
Furthermore, when therapy ends we will terminate our relationship and a
friendship is not possible.

Confidentiality

The professional ethics of a therapist prevent me from telling anyone else what
you tell me unless you give me written permission in the form of a release, there
is abuse/or neglect suspected, and/or you threaten to hurt yourself or someone
else. Some of these exceptions are required by law. I will let you know if the
boundaries of confidentiality have to be broken due to the requirements of the
law. If you are involved in a court preceding you can prevent me from testifying.
This “privilege” is your choice. The court may require me to testify in a child
custody or adoption proceeding, in cases where your mental or emotional health
is questioned, during a malpractice case, or when you are seeing me for a court
ordered evaluation or treatment. In these cases, we will further discuss your
confidentiality.

If you are a minor, there may be things that I need to discuss with your parent or
guardian. I will do my best to respect your privacy, however, your parent or
guardian has consented to treatment to offer you other options. Your parent or
guardian wants to know what goals you are working on and about the progress
you are making in therapy.

Duty to Warn

If at any time during therapy it becomes a concern that you, your child, or
someone in your family is a danger to themselves or others, I must contact the
police and sometimes the person that has been threatened. Confidentiality does
not apply in these cases.

Clients Rights

You, as the client, have rights in therapy. You have the right to know about our
therapy, about what other therapists may be more helpful or beneficial to your
particular situation, about our appointments, about financial responsibility,
about my qualifications, and about confidentiality. If you have questions about
any of these areas and feel that I have not fully explained your rights, just ask.

1. You have the right to decide not to enter therapy. If you wish I can provide
    you with the names of other therapists.
2. You have the right to end therapy. The only thing that you will have to do is
    pay for treatments you have already received.
3. You have the right to ask questions at any time, about what we do in therapy
    and to receive answers that satisfy you.
4. You have the right to keep what you tell me private, except for the situations
    that we already discussed.
5. You have the right to review your records and file at any time and to release
    copies of these records to other professionals.
6. You have the right to be treated with respect by your therapist.
7. You have the right to know your therapist’s experience and training.
8. You have the right to discuss your therapy with anyone you choose.
9. You have the right to read the ethical guidelines that your therapist has agreed
    to practice under.
10. You have the right to refuse any test, evaluation, or technique used.
11. You have the right to refuse treatment at any time, however, if you are court
    ordered to participate there may be consequences if you stop treatment
    imposed by the court.

Treatment of a Minor

Parents and children need to understand that there are benefits and cautions that
occur during the treatment of a child. Therapy can open and facilitate an
appropriate and sometimes inappropriate expression of the strong feelings that
can accompany the exploration of past trauma, transitions, and daily life
activities that affect your child.

As your child’s therapist, it is my primary responsibility to respond to your child’s
emotional needs. This includes contact with your child and his or her caregivers
and gathering information that is relevant to understanding your child’s welfare.
You may not always agree with the therapeutic recommendations made during
therapy. If this does occur, it is your responsibility to explore options with your
child’s therapist.
I ask that all of your child’s caregivers remain in frequent communication
regarding your child’s emotional needs. I also ask that you remember that I am
your child’s helper and not allied with any disputing party.

Please be advised that the confidentiality of your child includes:

 Keeping records that document all contacts relevant to your child’s case.
 Both parents have equal legal rights to the records barring court order
  limiting access. Specifically, this means that the records may disclose
  information that is sensitive and private.
 I am obligated to report any and all suspected child abuse and neglect to the
  Division of Children, Youth, and Families.
 The treatment of your child will not yield any recommendations regarding
  custody of your child. I recommend that if custody is an issue, you may be
  able to participate in mediation or a custody evaluation prior to settling your
  disputes in court.