Natalie Lane Eden, LLC
A Licensed Professional Counselor (Pennsylvania)
A Licensed Clinical Professional Counselor (Illinois)
315 Second Avenue, Warren, PA 16365
847-341-8019;
Telecounseling Informed Consent and Payment Contract for Services
Electronic Communications: It is important for you, the client, to realize the risks and limitations associated with electronic communications that include but are not limited to all types of video/Skype usage, e-mailing, chatting, cell phone calls, FaceTime, and texting. These modesinherently cannot guarantee 100% security and confidentiality for counseling purposes. Giving consent to usage of electronic communication means that you are aware and accept the potential risks and limitations to confidentiality with these devices.
There are some precautions that you, the client, can take to increase security and confidentiality: Communicate through a device that you know is safe and in a private area. Be aware of any friends, family, co-workers who might have access to your device. Be sure to exit Skype and turn any programs completely off after sessions.
Confidentiality: This counselor will make reasonable effort to protect and maintain the confidentiality of data gathered. Information will not be released without your consent, except for professional consultation if needed and unless required by law. As your counselor, I am required by law to disclose information pertaining to suspected child abuse; elder abuse; inability to care for one’s basic needs for food, clothing, shelter; and threatened harm to oneself or others. Courts may subpoena counseling records in select cases.
Suitability for phone and Skype counseling: Telephone and Skype counseling is not suitable for everyone. Results and benefits can also vary per individual. It is not suitable for those who are currently experiencing a life-threatening crisis; those suicidal and/or homicidal; those persons acutely psychotic; and those who are intoxicated. It should not be used as a substitute for medication that is managed by a psychiatrist or physician. If you are experiencing a psychological crisis it is advised that you call 911 or call to your nearest local emergency room. As a Licensed Clinical Professional Counselor in Illinois and a Licensed Professional Counselor in Pennsylvania USA, I am fully licensed to provide counseling only to those who reside in these two states.
Scheduled Sessions: Please be available by phone and/or at your device at the scheduled time. I will initially contact you at the appointment time. If no answer, I will try again in 10 minutes. If still no answer, you will be considered a no-show. You use up your own time when you arrive late for an appointment. If we are unable to connect or are disconnected during a session due to technical issues, please try again within 10 minutes and/or phone or e-mail counselor to reschedule.
No-shows are billed to the client for the individual session fee. Please contact counselor by phone or e-mail within 24 hours if you need to cancel a phone or Skype session. Leave a message if you get a voice mail.
Fees: Payment for telephone and Skype is due before the time of service. Your financial relationship with Natalie Lane Eden, LLC will continue for as long as she provides services or until you communicate your desire to terminate the counseling sessions. Fees are as follows:
A fee of $ per one hour individual telephone/Skype counseling session.
A fee of $ per half hour individual telephone/Skype counseling session.
Payment methods for telephone and Skype include all major credit cards. Payment information can be done online or gathered by phone. Most insurance does not cover telecounseling services. Accounts become delinquent after thirty (30) days. Payments not received within 120 days are subject to collections unless special arrangements have been made.
Consent to Treatment and Fees: I have read this Teleconferencing Informed Consent and Contract Payment for Services page and the Notice of Privacy Practices that is posted on this counselor’s websiteand agree to act according to everything stated as shown by my signature below:
Client:______Date: ______
I, Natalie Lane Eden, LPC, have discussed the issues above with the client (and/or the person acting for the client). My observations of the person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.
Therapist:______Date:______