Disclosure and Treatment Agreement Form

Disclosure and Treatment Agreement Form

My Philosophy and Background:

My therapeutic approach stems from a strengths-based perspective. I see each of my clients as a person who is inherently whole and who possesses the tools for their own healing. To support my clients in embracing these tools, I utilize several different therapeutic modalities that are tailored to my clients’ direct needs. I have been trained in Trauma Focused- Cognitive Behavior Therapy (TF-CBT) and also utilize concepts from Narrative Therapy, Person-Centered Therapy, Mindfulness Meditation, and Choice Therapy. If you have questions about my training, please ask.

I am a resource for social and community agencies and groups that may be of help to you during and after treatment. I will do my best to provide you with resources that are relevant to your presenting issue.

Licensure:

Registered Mental Health Counselor, Intern (#IMH12404), State of Florida

Education:

University of South Florida, 1979: Bachelor of Arts, Exceptional Education Emory University, 2009: Course of Study for Local Pastors Nova Southeastern University, 2015: Master of Sciences, Counseling, Mental Health Specialization

Client Rights and Important Information:

You are entitled to receive information about my methods and philosophy of therapeutic treatment, the duration of therapy, and the techniques I use.

It is the client’s responsibility to maintain current contact information with me. This means any address changes or other important detail changes need to be communicated with me so I may update your records.

Cancellations:
Please note that I require 24-hours notice for any cancelled appointments. Appointments not cancelled or rescheduled within the 24 hours prior to the appointment time will be charged the full session fee. I have set aside this time and have prepared specifically for you. If there is a true personal emergency, I will do my best to be flexible with rescheduling your session. ______INITIALS

You are free to seek a second opinion, request another therapist, or terminate therapy at any time. I ask that, if possible, you notify me in advance of any of these occurrences. ______INITIALS

Please note that there may be emotional stress, discomfort, or behavioral change as a result of therapy. Learning to think, act, and reflect in alternative ways may bring up uncomfortable emotions. The outcome of our work together is largely determined by the extent of your participation and collaboration with me, and while there can be great benefits from the therapeutic process, specific outcomes cannot be guaranteed. I am committed to helping you to achieve the goals that you have set and will support you as you implement healthy changes in life, relationships, personal self-care, and work. Communication, trust, and a sense of safety in our relationship are keys to therapeutic change. ______INITIALS

Confidentiality:

The Florida Statute 394.4615 provides that psychotherapists shall not disclose, without written consent of the client, any confidential communications made by the client, or any advice given, in the course of professional employment.

There are certain situations deemed by Florida law in which confidentiality must be broken. In these cases, I will try to notify you in advance. Exceptions to confidentiality include: if there is just cause to suspect you are intending to physically harm yourself or others; in the case of abuse or neglect of a child or a dependent person; or when subpoenaed by the court. ______INITIALS

Email communication is not secure and confidentiality cannot be assured. Therapeutic emails sent to me will be read before our next session and processed during the session. ______INITIALS

Phone calls and text messages extending beyond 10 minutes may incur a pro-rated charge. ______INITIALS

The age of consent for treatment in Florida is 18. If you are 18 or older and are seeking treatment, I will maintain confidentiality between you and me. If you give me written consent, I will share specified information with parents or guardians.
If you are under 18 and are my primary client, I may need to report to your parents/guardians serious concerns that I might have. If I am treating a couple or a family, I cannot guarantee that confidentiality will be retained between the members of the couple or family. ______INITIALS

Consultation:

In order to give you the most complete and helpful care, I sometimes consult with other colleagues and professionals in the field. In these cases I may discuss details of your case, however specific identifying information will not be provided and confidentiality will be maintained between these individuals and myself.

Fees:

I do not take insurance.Each session must be paid for on the day of service. One hour of counseling is $65, and I will accept cash, check, or charge.

Limitations of Services:

Please note that I am not available 24 hours a day. I am available Monday-Friday from 9am-6pm, and some special appointments if accommodations are made beforehand.

I am unable to provide emergency services. If you have an emergency, please call 911 or visit your nearest emergency room.

If you have an urgent but non-emergency matter and it is outside of business hours, I will return calls as soon as possible. I make every effort to do this within the same business day. Weekends and holidays may warrant a longer time for response.

If I plan to be out of reach for more than 24 hours, I will notify my clients as soon as possible. In the case that I am out of town for several days, I will ensure that you are connected with a qualified colleague during that time.

I have read the preceding information and I understand my rights as a client or as the client’s responsible party.

Print Client’s name ______

Client Signature______Date______

Guardian’s Signature ______Date ______

Susan S. Lewis, M.S., RMHCI ______Date ______