Changes Counseling & Consulting
Welcome to Changes Counseling & Consulting. I am delighted you have chosen us. This is an important and critical step to making the “changes” you are seeking. This document is intended to provide you with information about my agency and the services provided to you. If you have any questions please feel free to ask. At the end of this document you will be asked to provide your signature indicating that you have read and agreed to all the information provided.
About Me
I am Cherie J. McGahee MSW, LCSW. I received my Masters degree in Social Work at Texas A&M- Commerce in 2006. I obtained my clinical licensure in 2010 and have worked in the behavioral health field since obtaining my license. I am a member of the National Association of Social Work (NASW) and am bound by the NASW Code of Ethics. I would be happy to provide you with these ethics at your request. I have been trained in PCIT – Parent Child Interactive Therapy. I am also trauma informed and am working on certification as a TF-CBT therapist.
Complaints
If you have any complaints I encourage you to discuss them with me first. If you are still not satisfied and wish to file a complaint or grievance you may contact the
Texas Board of Social Work Examiners Complaints Management and Investigative Section P.O. Box 141369 Austin, Texas 78714-1369 or call 1-800-942-5540 or visit http://www.dshs.state.tx.us/socialwork/ to request the appropriate form or obtain more information. Initials ______
Mission Statement
Changes Counseling & Consulting is dedicated to providing ethical and competent services to children, adolescents and adults through individual, family, couples, and group therapy as well as consulting for community agencies and organizations.
Services & Cancellation Policy
Counseling is provided to children, adolescents, and adults using a wide range of therapeutic approaches based on the individual, couple, or families needs and with their input. The first session is used for gathering information and getting to know the individuals who will be attending counseling and usually last from an hour to an hour and a half. Following sessions are 50-60 minutes long and occur weekly or bi-weekly depending on their needs. An individual will be responsible to pay unless a 24 hour notice is given or there is an agreement between both parties that the individual was unable to attend or give notice due to circumstances beyond their control. Initials ______
Crisis
For the most part I am available Monday through Friday from 9am to 5pm. I do not answer calls while in session. You may leave a message and I will do my best to return your call the same day. If you are in a crisis and feel you are a harm to yourself or someone else you will need to go to the emergency room closest to you.
Fee Agreement
Our fees are due at time services are rendered and are listed below:
· Evaluation & Diagnostic Session (1st visit) – $175.00
· Office visit (50-60 mins) Individual, Couples, and PCIT - $125.00
· Family Sessions (50-60mins) – $150.00
These fees may be billed to your insurance company however you are ultimately responsible for the full payment of fee.
Services not billed to insurance companies are listed below
· Consultation for community agencies and organizations - $75.00/ hr
· Report or letter writing $50.00/hr
· Telephone conversations lasting longer than 15 mins
· Site/School visits, meetings $75.00/hr
· Consultation with other professionals $75.00/ hr (including phone consults)
· Court preparation, transportation, and attendance $75.00/hr
A sliding scale fee is accepted for those who fall below the poverty level. This will be decided after adequate proof of income has been submitted.
The following is a fee agreement between Changes Counseling & Consulting and
______. You agree to pay $______at the beginning of each session.
Initials______
HIPAA Notice, Confidentiality and Limitations
The Notice of Privacy Practice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also outlines your rights to access and control your PHI. Communication between therapist and client will remain confidential and will not, with the exception of those situations outlined below, be revealed to other parties outside of Changes Counseling and Consulting unless client gives written and specific consent to release the information. A “Consent to Release of Information” will need to be signed by the client before any information is released. Records of our work together are kept at Changes Counseling & Consulting and are protected from possible breaches of confidentiality. Your record never leaves the office. You may request copies of these records at any time by setting an appointment to obtain the records. You may also request a summary of your records. The following are limits to confidentiality and do not require a signed consent:
· If you tell me you are going to harm yourself or someone else then I am required by law to do whatever I can to prevent that harm. This includes but is not limited to contacting law enforcement, those in danger, and/or legal guardians.
· If you disclose abuse or neglect of children, the elderly, or a disabled person.
· If you disclose misconduct by a mental health professional
· Records used for audits or certification
· When records are court ordered by a judge
· For purpose of filing claims with insurance companies and third party billing entities.
If you believe your privacy has been violated you may complain to us or to the Secretary of Health and Human Services.
Please initial indicating your understanding initials ______
Consent to Transport
I (circle) do or do not give consent for Changes Counseling & Consulting to transport my child for purpose of providing counseling services.
Initials ______
Consent to Treatment
I have read or had read to me this document. All questions I had have been answered to my satisfaction and I understand I have the opportunity now and in the future to discuss any other questions I may have. I agree to the policies, procedures, and fees explained in this document. I accept counseling for myself or my child and am voluntarily signing this form. I understand I may cancel services at any time. I understand that no promises have been made to me as to the results of treatment.
______
Client Signature Date
By signing below I declare I am the parent or legal guardian of said minor child and I therefore give consent for treatment of said child by therapist.
______
Name of Minor Child
______
Signature of parent or legal guardian Relation to child
______
Staff Signature
4 Created 1/17/2016