1
Office Policies and Information for Informed Consent
Welcome to Green Light Counseling Center. I appreciate your giving me the opportunity to be of help to you. Choosing to begin professional counseling is often a tough decision. It is my hope that this brochure will begin to answer some of the many questions you have about my practice and to help you to make an informed consent to counseling. It is important to me that you understand how we will work together and what the risks and benefits are to you. Because you will be putting a good deal of time, money, and energy into therapy, you should choose a therapist carefully. I strongly believe you should feel comfortable with the therapist you choose, and hopeful about the possibilities.
Let me introduce myself…
My name is Elizabeth S.Maddaford and I am a Licensed Clinical Social Worker. You can call me Beth. I received my Masters in Social Work from the University of Texas at Arlington in 1996. I have been licensed by the Texas State Board of Social Work Examiners since 1996 to practice social work and since 2002 as an independent practitioner. I am a member of the National Association of Social Workers. I have worked in community agencies, as well as public schools, working with individuals, couples, and families. I believe that people can make changes that promote healthier life choices and relationships.
What to expect from our relationship?
As a professional, I will use my best knowledge and skills to help you. Our relationship will be a strictly professional relationship. In a professional therapeutic relationship there are limitations. First, I am only licensed to practice social work counseling –not law, medicine or any other profession. I am not able to give you good advice from these other professions. Second, ethically, I can only be your therapist; I cannot have any other personal, social, or business relationship during, or after, the course of therapy. This makes accepting gifts, bartering and trading services, and attending family functions, unethical. Last, our relationship is confidential in nature. You can trust me to not tell anyone else what you tell me, except in certain limited situations. I explain what those are in the “About Confidentiality” section. In order to protect your privacy, if we meet by chance in a public setting, I will not initiate a greeting.
What are the risks and benefits of counseling?
As with any powerful treatment, there are some risks as well as many benefits with therapy. In therapy, major life decisions are sometimes made, including separation within families, development of other types of relationships, changing employment settings and changing life-styles. These decisions might result in an individual questioning many of their beliefs and values about themselves and the world. This could result in feelings of anxiety, sadness, loss, anger, guilt as well as other uncomfortable feelings. Clients may recallmemories that are upsetting. These memories could bother a client at work or other places. As your counselor, I will be available to support you as you go through any negative effects of our work together. The success of therapy depends on the clients’ honesty about their feelings and situation; as well as, the clients’ commitment to genuine effort in working towards their goals.
While you consider these risks, you should also be aware that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have the chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may be clearer. I do not work with clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress. If however, I believe you will benefit from a treatment I cannot provide, I will help you to get it. Additionally, I cannot continue to treat you if my treatment is not working for you. If you would like to work with another counselor, at any time, I will do my best to help you find a qualified person.
About appointments
Clients are seen by appointment. Appointments are made by calling/texting 817-690-2842,by emailing your request to , or emailing through the practice portal. I maintain my own appointment calendar, so if I do not answer please leave your name and phone number and I will call you back for scheduling. Appointments are 50 minute sessions. If your appointment is scheduled before 8:30 AM or after 5:00 PM be aware the front doors will be locked. I will open the door for you right before your session. During the initial session, we will discuss the frequency and number of sessions needed. This is variable and dependent on many factors. We will try to schedule sessions for both your and my convenience. I will tell you at least a few weeks in advance of my vacations or any other times we cannot meet.
Cancellations
Cancellations must occur at least 24 hours before your scheduled appointment; otherwise you will be charged a $50 cancellation fee. Changes in appointments by either of us should be made with as much advance notice as possible, as a sign of our mutual respect.
Payment for Services
My standard fee is $125.00 per session. Unless otherwise arranged, payment for services is to be made in full at the beginning of each session. Payment for my services may be made by cash, credit/debit card (Visa/MasterCard/Discovery), or personal check. Many clients elect to use their flex-spending account cards to pay for services. Please be aware that you will be charged a $25 fee for returned checks or denied credit cards.
If you have medical insurance coverage, for which I am an in-network provider, I will file it and accept the contracted rate. If you have medical insurance, for which I am an out-of-network provider, I will be happy to furnish a statement of service, so that you may file it with your insurance company for any eligible reimbursement.
Court Related Processes
Although it is my goal 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. Should you subpoena Elizabeth S. Maddaford, as a factual witness, or involve her in court-related processes, you will be charged a retainer fee of $1500, with a charge of $240 every hour she is involved in case preparation, phone calls, travel, and witness time, etc. Should you issue Elizabeth S. Maddaford without her approval (see above), the subpoena will be directly turned over to her attorney and a bill will be rendered to you for immediate retainer fee payment.
About confidentiality
I will treat with great care all the information you share with me. It is your legal right that our sessions and my records about you are kept private. In all, but a few rare situations, your confidentiality (that is, your privacy) is protected by state law and the rules of my profession. Here are some of the most common cases in which confidentiality is not protected:
- By law, suspectedabuse of a child, abuse of an elderly person, abuse of a disabled person, and abuse of a mental patient, must be reported to the authorities.
- If you make a serious threat to harm yourself and/or another person, the law requires me to try to protect you and/or that other person. This usually means telling others about the threat and seeking assistance.
- If you are involved with a court case, (like a child custody case, adoption case, criminal prosecution case, a therapy negligence case or other types of cases) and it is disclosed that you are seeing me, I may then be ordered to show the court my records. Please consult your lawyer about these issues.
- If you were sent to me by a court or an employer for evaluation and treatment, the court or employer expects a report from me. If this is the situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable with telling.
By signing this consent form, you are giving your consent for me to share confidential information with all persons mandated by law and you are also releasing and holding harmless this therapist from any departure from your right of confidentiality that may result.
If your records need to be seen by another professional, or anyone else, I will discuss it with you. If you agree to share these records, you will need to sign a release form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits.
If I must discontinue our relationship due to illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access. By signing this information and consent form, you give your consent to allow another licensed counselor selected by this therapist to take possession of your file and records and provide you with copies upon request, or to deliver them to a counselor of your choice.
Communication consent
By signing this consent form, you are giving me consent to communicate with you by mail, email, and/or phone call/text. I will protect your privacy by using my name only when sending a letter or leaving a message. Please be aware that email and text messages are not secure ways to communicate confidential information. I would prefer that you leave a voice message, speak to me directly, or use the secure practice portal to email sensitive information. I will be happy to communicate about routine things such as appointments through emails and/or texts. Please inform me of any address or phone number changes as soon as you are able.
Emergency Services
There will be times I will not be available; I am unable to provide services 24 hours per day. In the event that you become in need of emergency counseling services when I am unavailable, you may contact the following for emergency services in Tarrant County: Crisis Intervention-Fort Worth at 817-927-5544; John Peter Smith Hospital emergency roomat 817-927-1110. In Dallas County: Dallas Suicide and Crisis Center at 214-828-1000;Parkland Psychiatric Clinic at 214-590-5536 or the Parkland Emergency Room at 214-590-8761.
Consent to Treatment
I, the undersigned client (or his or her parent or guardian), understand that I have the right not to sign this consent form. My signature below indicates that I have read and discussed this agreement. I voluntarily agree to receive mental health assessment, care, treatment, or services, and authorize the undersigned therapist to provide such care, treatment, and 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 the undersigned counselor at any time. However, premature termination may result in failure to achieve therapeutic outcomes.
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.
______
Client (Signature) Parent/Guardian (if client is a minor) Date
______
Spouse/Partner Date
If using Insurance/EAP benefits:
I authorize the release of required private healthcare information, in the course of my treatment with Elizabeth S. Maddaford, LCSW, to process third-party claims for benefits. I am responsible for all outstanding balances incurred by me including insurance deductibles and co-payments and unpaid claims. I authorize claim’s benefits for above client to be paid directly to Elizabeth S. Maddaford, LCSW.
______
Signature of Client or Responsible Party Date
Notice of Privacy Practices
Receipt and Acknowledgement of Notice
Patient/Client: ______
Date of Birth: ______
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Green Light Counseling Center’s Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Elizabeth S. Maddaford, LCSW.
______
Signature of Patient/ClientDate
______
Signature of Parent, Guardian or Personal Representative*Date
______
*If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).
□ Patient/Client Refuses to Acknowledge receipt:
______
Signature of Staff MemberDate
Personal Information (Please Print)
Client’s Name: ______
DOB: ____/____/____ Age: ____ Sex: ____M ____F
Married ______Single ______Divorced ______Widowed ______Cohabitate ______
Address: ______City______Zip______
Telephone numbers: Home: ______Cell: ______
Email address: ______
May I leave a brief message on your answering machine, voicemail, email or text? Yes ______No______
Parent/Guardian Name (if applicable): ______
Emergency Contact Name: ______Relationship: ______
Telephone number: ______
Primary Care Physician: ______Phone: ______
Have you had counseling and/or psychiatric care before? Yes______No______
Current Psychiatrist: ______Phone: ______
*********************************************************************************************************************************************
Fill out for Spouse/Partner (If applicable):
Name: ______DOB: ____/____/____ Age: ______
Employer: ______Work Phone: ______
Primary Care Physician: ______Phone: ______
Has your spouse/partner ever had counseling and/or psychiatric care before? Y_____ No_____
Current Psychiatrist: ______Phone: ______
*********************************************************************************************************************************************
Fill out for insurance claims (if applicable)
Primary Insurance: ______Phone: ______
Insurance Company’s Address: ______
Name of insured: ______DOB: ____/____/____ Sex: ____M ____F
ID# of Insured: ______Group #: ______
Relationship to Client: ______Employer Plan: ____Yes ____No
Employer: ______
*********************************************************************************************************************************************How did you hear about Green Light Counseling Center or who referred you? ______
Green Light Counseling Center, 817-690-2842