This document sets forth a standard disclosure statement for use by a professional counselor. The counselors provide this disclosure statement to their clients to limit their potential liability and to set forth the rights and obligations of both parties during the relationship. In addition, this form sets out fees, insurance, confidentiality, and risks. This document should be used by counselors that want to formalize an agreement with their clients.
This document sets forth a standard disclosure statement for use by a professional counselor. The counselors provide this disclosure statement to their clients to limit their potential liability and to set forth the rights and obligations of both parties during the relationship. In addition, this form sets out fees, insurance, confidentiality, and risks. This document should be used by counselors that want to formalize an agreement with their clients. Professional Counseling Disclosure [Pick the date] <WIDGET> PSYCHOTHERAPY Professional Counseling Disclosure Statement Therapy such as counseling can be a long commitment of time, and money, therefore a counselor should be carefully chosen. You should be at ease, and confident with the counselor you choose. This Disclosure Statement is designed to help you make your decision in choosing us as your therapists in an informed consensual manner. I. Counseling Counseling requires your very active involvement and offering your views and responses when they are important to you. This affords the counselor’s efforts to give input, and feedback in order to help you see that you and you alone can change your thoughts, actions and feelings. I will expect you to be open about what you are thinking. No help can be gained without dialog. My jobs are to guide, calm, and encourage you. In our counseling, you may have record-keeping, reading assignments, calisthenics, and practice tests. You most certainly will have to make long term efforts in relationships in order to have a positive outcome from your counseling sessions. Your life outcome will in fact depend upon you, and your willingness to change. I will ask for regular reviews of our progress and if treatment is not progressing, I may refer you to another professional. I will fully discuss this ahead of time so that we can come to an agreement. I see therapy as collaboration between counselor and counselee, and by the second session I will be able to offer you my initial response, and tell you what I think, and feel about your situation, and recommend a treatment plan. © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 3 The treatment plan will approximate the costs, and time commitment involved, along with other aspects of your situation in a meticulous detailed manner. I expect us to agree upon the treatment plan, and your commitment to strive to adhere to its progress goals, and methods. II. Risks Risks of isolation, rage, dissatisfaction, guilt, anxiety and sadness may occur. You may recall distasteful aspects of your times past; and difficulty with people important to you may occur; notwithstanding your and my greatest efforts, counseling may not work out well for your individual situation. Some changes you may make could lead to a deterioration of your tribulations. Notwithstanding, therapy has been scientifically demonstrated to be of benefit. You will have the occasion to "talk things out" utterly, which might bring with it the lifting of depression, fear, anxiety, or anger. You may be better equipped to cope with social and family relationships; your people skills may improve dramatically even leading to job promotion. III. Meetings The first introduction and information gathering session will take one and one half hours, but future sessions are at one hour intervals. Typically we will book and schedule sessions more often over the first three months and then monthly for several months. An appointment is a contract between us. We agree to be here and on time, if you are late we will probably be unable to meet for the full session as it is likely that another appointment is scheduled after yours. Your session time is reserved for you. Please make this your first priority we may in the future bill for missed scheduled sessions. IV. Fees You are responsible for assuring that services are paid for; this makes it more likely that the counseling sessions will work. The current regular fee for therapy is $<___> per hour. In financial hardship we may, before the end of our first meeting, negotiate a sliding scale fee. © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 4 V. Insurance You must pay for each session at the end of the session. If you have health insurance which may pay a portion of the costs for your therapy, I will provide you with insurance claim forms. However, please bear in mind that you are responsible and not your insurance company, for paying the fees. As a Licensed <___________>, my services for evaluation and psychotherapy are reimbursable to you fully or partly under many health insurance plans. For some plans you may need to get a physician's referral for psychotherapy, so search your plan carefully. You can apply for reimbursement by simply mailing a completed copy of your companies Claim Form which you can get from your employer's Benefits Office or by calling the insurance company. Insurance Claim Forms are now guided by HIPAA regulations and as such they become part of your permanent medical record, its possible influence on your future should be discussed with your attorney. VI. Confidentiality The confidentiality of our conversations, including your records, is legally protected by federal and state law, including HIPAA, and by my profession's ethical principles. These are outlined in my handout on Confidentiality and Psychotherapy, which is also being provided to you. I make every effort to preserve the confidentiality and anonymity of all my clients. Other people do not see my clinical records. I ask each client to preclude disclosing the distinctiveness, or names of any other clients being seen at this office. VII. General Information Each counselor has developed rules or methods which have worked well doing therapy. I often take notes and also ask my clients to take notes, both during the session and at home. This is a vital factor in personal change and I expect my clients to take notes in order to maximize your therapy dollars. © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 5 VIII. Records You have the right to review your medical record within HIPAA limitations at any time, and to obtain copies for other professionals to use. I will keep your case records in a secure place for at least 12 years, after our last contact. IX Contact Person If, there is an emergency or I become concerned about your personal safety or the possibility of your injuring someone else, I am morally and legally obliged to contact the appropriate officials, or the person listed as a contact on your intake forms. X My background PROFESSIONAL ORIENTATION AND TRAINING: <Insert Information> COUNSELING BACKGROUND: <Insert Information> © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 6 XI Code of Ethics: I am a licensed <__________>, which means that I abide by the ethical and legal responsibilities outlined for Mental Health practitioners. Like any other health care professional I have an ethical responsibility. I fully abide by the Ethical Principles of the <___________> Association and the <_____> Board of Examiners for Licensed <____________>. XII. Limitations: I am not licensed to practice law, medicine, or another profession and am neither willing nor capable of giving you trustworthy advice from other professional points of view. XIII Non-Discrimination: In my professional practice, as Licensed <_____>, I nor my practice discriminate in accepting and treating patients, clients, students or others on the basis of: age, gender, marital status, race, color, religion, ancestry, national ethnicity, location of residence, physical or mental disability, veteran status, or in violation of any federal, state or local law. This statement is made in accordance with federal, state and local regulations. XIIII. Agreement I, the counselor, find no reason to believe that this client is not fully competent and of competent mind to give full consent to treatment. ____________________ ___________ Counselor Date: I have read (or had read to me) the contact above, discussed it, and where I was not clear about any point, had my questions fully answered, and I agree to comply with this contract, I hereby agree to enter into psychotherapy with this counselor as indicated by my signature below. ______________ ________ Client Date: © Copyright 2011 Docstoc Inc. registered document proprietary, copy not 7
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