CLIENT INFORMATION AND CONSENT
Transitions Counseling Services of North Texas, PLLC.
6136 Frisco Square Blvd. Suite 400. Frisco, TX 75034
Phone: 214-418-4604
I welcome you! It is my desire to insure that your participation in counseling is a most productive and satisfying one. In order to facilitate a therapeutic relationship, I have set forth certain information which will enable you to make an informed consent to counseling.
Counseling
My name is Katie Hilton and I am a licensed clinical social worker. I have a Master’s degree in Social Work with an emphasis on direct practice mental health fromThe University of Texas at Arlington.
Mental Health Services
While it may not be easy to seek help from a mental health professional, it is hoped that through therapy you will change in the following ways: 1) gain greater insight into your situation and feelings, 2) develop expanded conceptualizations of your life, relationships, circumstances, and future; 3) move toward resolving your concerns; and 4) forge a life plan that promotes greater realization of your human potential, happiness, and success. Therapy is a process that requires that both counselor and client be willing to work. You will be helped and encouraged to set specific goals for yourself. These directives will be addressed as a team. My role will be to help you reach your goals.
Appointments and Cancellations
Initial appointments are made by callingKatie Hilton LCSW at 214-418-4604.Once therapy has begun, please call me, Katie Hilton LCSW to cancel or reschedule an appointment at least 24 hours in advance. Failure to do so within this time frame will result in you being charged $100.00 for the missed appointment. If you experience a life-threatening emergency, please go to your nearest ER or call 911.Otherwise, you may leave a non-urgent message on my voice mail, and I will return your call at a suitable time.
Number of Visits
The number of sessions needed depends on many factors and will be discussed by the counselor.Counselees may also be transferred to another counselor or referred to a licensed professional outside of Transitions Counseling Services of North Texas PLLC,should it be considered in the client’s best interest to do so. In preparation for termination or transfer, your current counselor will discuss with you and facilitate you in the processing of these options.
Length of Visits
Therapy sessions are normally 45-50 minutes in length but may take longer for psychological testing or the initial assessment visit.
Relationship
Your relationship with the counselor is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that the therapist not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. The counselor cares about you but is not in a position to be your friend or to have social or personal relationship with you. Out of respect for your privacy, I will not initiate contact with you in a social setting and will be brief if you initiate the contact with me.Gifts, bartering, and trade services are not appropriate and should not be shared between you and the counselor.
Payment for Services
The charge for your sessions is based upon the counselor’s contract rateof $125.00 per 45 - 50 minute session. Within contract guidelines, the undersigned therapist will look to you for full payment of your account, and you will be responsible for payment of all charges. If you are filing with an insurance company, it is recommended that you determine your co-payment before your first visit by calling your insurance company. In addition, the co-pay may be different for the first visit than for subsequent visits depending on the length of the session. You are responsible for and shall pay your co-pay portion of the undersigned counselor’s charge for services at the time the services are provided.
Confidentiality
Although it is the goal of the undersigned counselor to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure of your records or testimony is required by law, you will be responsible for and shall pay the costs involved in producing the records and the therapist’s normal hourly rate for time involved in preparing for and giving testimony. A retainer fee of $2,400.00 that is due at the time a subpoena is served. The charge for court-related services of any kind is $300.00 per hour rounded to the nearest 15 minute interval including drive and wait time. Fees incurred for these services will not be filed with your insurance company. Such payments are to be made at the time or prior to the time the counselor renders the services.
Discussions between a counselor and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecution; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn or disclose; fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist; or the filing of a complaint with the licensing board. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist where you and the therapist will discuss this matter further. By signing this information and consent form, you are giving your consent to the undersigned therapist to share confidential information with all persons mandated by law and with the agency that referred you and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services, and you are also releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result.
I consent for the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers, and I will IMMEDIATELY advise Katie Hilton LCSW in the event of any change:
ADDRESSTELEPHONE NUMBER
If it is necessary to leave a brief voice message for you,to return a call, or to reschedule an appointment- you release Katie Hilton LCSW, to do so at ______(voice mail or phone recorder number). I also give Katie Hilton LCSW consent to send me information via e-mail at ______
Duty to Warn
In the event that Katie Hilton LCSW reasonably believes that I am a danger, physically or emotionally, to myself or another person, I specifically consent for Katie Hilton LCSW to warn the person in danger and to contact the following persons, in addition to medical and law enforcement personnel:
NAMETELEPHONE NUMBER
______
______
______
Signature: ______Date: ______
1
Risk of Therapy
Therapy is the Greek word for change. You may learn things about yourself that you don’t like. Often, growth cannot occur until you experience and confront issues that induce you to feel sadness, sorrow, anxiety, or pain. The success of our work together depends on the quality of the efforts on both out parts, and the realization that you are responsible for lifestyle choices/changes that may result from therapy.
After-Hours Emergencies
For emergencies you may attempt to reach me at 214-418-4604(Emergencies are urgent issues requiring immediate action). In case of a life-threatening emergency go to the nearest ER or call 911. Do not wait for me to return your call in the case of life-threatening emergencies. The appropriate facilities or authorities will contact me upon your consent.
Counselor’s Incapacity or Death
I acknowledge that, in the event that Katie Hilton LCSW becomes incapacitated or dies, or leaves Transitions counseling Services of North Texas, PLLC, it will become necessary for another therapist to take possession of my file and records. By signing this information and consent form, I give my consent to allow another licensed mental health professional selected by Katie Hilton LCSW to take possession of my file and records and provide me with copies upon request or to deliver them to a therapist of my choice.
Consent to Treatment
I, voluntarily, agree to receive Mental Health assessment, care, treatment, or services, and authorize Katherine Hilton LCSW, TCSNT,to provide such care, treatment, or services as are considered necessary and advisable.
I understand and agree that I will participate in the planning of my care, treatment, or services, and that I may stop such care, treatment or services that I receive through Katie Hilton LCSW at any time.
By signing this Client Information and Consent Form, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
______
ClientDate
______
Address
1
*If a Minor is receiving counseling services please fill out the following form.
Permission for Professional Services for a Minor:I have the legal authority to seek and grant permission for professional services for minor child,
______, Birth date _____/_____/_____ ,
______, Birth date _____/_____/_____ ,
______, Birth date _____/_____/_____ ,
______, Birth date _____/_____/_____ ,
there being no legal decree disallowing my authority to assume such responsibility.
______
Client/Parent Date
Client Family member signatures: All family members who are involved in this therapy need to sign below, indicating understanding of these policies and procedures. If you have any questions, please discuss them with your therapist before you sign.
______
Client Date
______
Client Date
______
Client Date
______
Client Date
Witnessed by:
______
CounselorDate
______
Witness(print and sign name)Date
1