Bridges to Healing Philosophy of Counseling

Informed Consent

This is a disclosure statement about the individual and/or group therapy relationship, the factors involved, and clarification of the rights and responsibilities of the therapist/counselor and client. A clearly defined structure for therapy creates the safety and support needed to take risks and feel empowered and healthy. Please read these guidelines carefully.We will go over them verbally, and you may ask questions for clarification before signing your consent to start therapy.

Bridges to Healing counselors may be Licensed Therapists, Registered Interns, Trainees, volunteers, and/or state certified Sexual Assault, Domestic Violence or Crisis Intervention Counselors. Professional consultation and supervision is provided to all counselors. Marriage and Family Therapists and Licensed Clinical Social Workers are licensed through the Board of Behavioral Sciences in the state of California. You may check the good standing of any license at

Bridges to Healing Philosophy of Counseling:

Bridges to Healing utilizes a philosophy of therapy called Feminist Therapy which recognizes how our gender, race, class, age, sexual orientation, (dis)ability, religion, etc. and power dynamics in society impact our self- concept and well-being. We believe that you are the expert on your own experiences and see therapy as one tool that can be used to become more empowered, heal from past experiences, or grow in new directions. We will focus on your strengths and facilitate a safe space to work on mutually agreed upon goals based on the issues that led you to seek assistance. We use a variety of techniques in therapy including person-centered approaches, cognitive, and emotive therapies. We might suggest that you consult with a physician or health care provider if we feel that your symptoms might benefit from other treatments. In most cases, we will work concurrently with other resources that you find helpful including support groups, body work, psychiatric medication, alternative/holistic remedies, hypnosis, etc. When you are working with another health care provider, we will need a release of information from you in order to communicate about your care. We will take care to only share necessary information and will disclose to you each time any communication between providers occurs.

Risks of Counseling:

There are risks and benefits of seeking therapy. Sometimes painful feelings and issues emerge as we work together—it seems to get worse before it gets better. Approaching thoughts or feelings you have tried not to acknowledge may be very difficult. Relationships may change or end due to new beliefs, behaviors, or decisions you make. While it is rare, counseling may uncover such profoundly intense emotions that temporary disability or hospitalization may occur. Counseling and therapy are not exact sciences, and there are no guarantees that our work together will provide you with the outcomes you desire. If you are dissatisfied with services, we hope that you will provide us with that feedback so that we may try to remedy the problem, or find referrals more suitable to your needs. We take your feedback seriously and treat it with respect and concern. Most clients who take the risk to participate in therapy find it transformative and empowering.

Confidentiality:

With specific exceptions, all client communication is confidential. You have the right to confidentiality. No information can be shared with anyone outside the practice, regardless of their relationship to the client, without written consent in the form of a signed “release of information” form available from your counselor. There are cases where we are legally mandated or ethically allowed to break confidentiality:

We have reason to suspect that a child, an elderly person, or a dependent adult is being abused or neglected, or you disclose information indicating such abuse;

We believe that you are in danger of harming yourself or someone else;

By subpoena, deposition, or order of the court.

Bridges to Healing will assess additional fees for time and resources utilized responding to legal or criminal justice matters.

We will respond to these exceptions to confidentiality as collaboratively as possible, and with your best interest in mind. If you feel suicidal or engage in self-harming behaviors, we will explore all other options with you to keep you safe before calling a crisis intervention team.

With at least two weeks prior notice we willprovide written documentation of our sessions, write a summary of your client file, or provide information within our scope of practice at your request. We do not provide court-mandated treatment, child custody or placement evaluations. We do not perform psychiatric assessments.

Records of our therapy sessions are kept in locked files, in a secure location, where they cannot be accessed by anyone other than Bridges to Healing personnel. In the event of your counselor’s own emergency or severe illness, we have designated another Bridges to Healing mental health care professional (also bound by confidentiality) to access our files and contact clients.

Boundaries and Arrangements:
We provide between 45-60 minute individual sessions, as agreed upon at the start of treatment with your therapist/counselor. Group sessions are usually 1 hour and 30 minutes. If you are late for your appointment, we are unable to extend your session time, and your session fee remains the same.We require at least 24-hour advance notice for cancelled appointments. If you do not call to cancel at least 24 hours in advance, or you do not show for an appointment, you will be charged ½ of your session fee. After 3 cancellations/no shows, a preferred appointment time cannot be held or guaranteed.

The preferred method for communicating cancellations or other information regarding therapy or your appointment is by phone. Email is not a secure method of communication, and we do not participate in online therapy. You should discuss with your therapist/counselor regarding their individual policy on the use of email for appointment scheduling.

Wedo not engage in relationships other than the therapeutic relationship with clients. The therapy relationship, while somewhat intense, is unlike a friendship. Specific boundaries are set for your protection, to provide a safe space without imposing our personal feelings, life choices, or advice upon you, which can disrupt the therapeutic process. Wenever have sexual or intimate relationships, friendships, business partnerships, etc. with current or former clients. In order to respect/protect your therapy process, we may choose not to answer personal questions that are unrelated to ourprofessional training or competence.

Wedo not provide 24-hour services, crisis or emergency services. Wedo not carry emergency pagers or cell phones. Wewill typically respond to voicemail messages by the end of the next business day. In case of an emergency whereinyou feel thatyou cannot keep yourself safe, you agree to call 911, go to the nearest hospital, or use appropriate emergency hotlines. Wewill provide numbers of crisis lines that can help you in the event of a crisis between sessions. When weare away from the office, wewill give you notice of our absences in advance. If necessary, you may request sessions with another Bridges to Healing therapist/counselor who can assist you during an absence.

Fees:

Our fee for individual therapy is $150 per therapeutic hour, and may vary between individual therapists. Group rates range from $50-100. The fees for any services provided by Bridges to Healing staff are determined prior to the first session. This fee is to be paid at the beginning of each session. We do not bill insurance or MediCal/Medicare at this time. We cannot accept barter for therapy, as this would constitute a dual relationship. Calls in between sessions not exceeding 15 minutes are typically free. If calls or messages exceed more than 15 minutes a week, a prorated session rate may apply. There is a $25 fee for checks not paid due to insufficient funds.

We reserve a percentage of our appointments for sliding scale clients. We will let you know, upon request, if any of these spaces are available. We also maintain referrals for low-cost, sliding scale counseling and other social services.

Fees are subject to change, and will increase by $5 beginning in January of every even-numbered year. Current clients who have been seen regularly for at least one year, and whose fees have not increased in the previous nine months, can expect their fee to increase in January of every even-numbered year. If a fee increase presents undue hardship, the therapist will engage open conversation with the client in an effort to arrive at a mutually beneficial fee arrangement. A break in therapy may result in reconsideration of fees upon client’s return to therapy. Ninety days advance notice will be provided in writing prior to any fee increase.

Termination:

Termination is usually mutually agreed upon by the client and the therapist/counselor. As we meet the goals we set, we will enter a process of ending our therapy relationship. You have the right to end therapy at any time, for any reason. If it is foreseeable that our work together will become outside of our area of competence and training to help you, wemay refer you to other professionals that webelieve might meet your needs. Wecannot, however, guarantee that they will be available to provide services. If you threaten or commit verbal or physical violence, or harass us or other professionals in the office, wereserve the right to terminate our therapy relationship immediately.

In working toward a common goal, you and your Bridges to Healing therapist/counselorwill form a unique partnership based on trust, clear boundaries, and confidentiality. It is our hope that this will prove to be empowering and beneficial to you.

Agreement:

Ihave read this statement, had sufficient time to be sure that Iconsidered it carefully, asked any questions, and understand it. Iconsent to enter therapy with ______. Iunderstand my rights and responsibilities as a client. Iunderstand the limits of confidentiality. Iagree to pay a fee of ______per session.

Signed: ______Date: ______

Client

Name (Printed):______

Signed: ______Date: ______

Parent/legal guardian (as applicable)

Name (Printed):______

Witness:______Date: ______

Bridges to Healing, Incorporated2014