James B. Carroll, MA, LPC, NCC, CCMHC, MAC, CH, RPT-S

James B. Carroll, MA, LPC, NCC, CCMHC, MAC, CH, RPT-S

106 Four Seasons Center, Suite 103B

Chesterfield, MO 63017

314-651-6679

Informed Consent

Privacy of Information Shared in Counseling/Therapy

Your Rights and My Policies

About Me:

My name is James Carroll, DBA James B. Carroll, LPC, LLC. I have an MA in Professional Counseling from Lindenwood University and a BA in Psychology from Southern Illinois University. I am a Licensed Professional Counselor in the State of Missouri and a Licensed Clinical Professional Counselor in the State of Illinois. In addition, I am a National Certified Counselor, a Certified Clinical Mental Health Counselor, a Certified Hypnotherapist, and a Registered Play Therapist-Supervisor. I generally take a cognitive-behavioral approach to counseling, as well as utilizing hypnosis, EMDR, principles of Theraplay®, and play therapy. My clinical areas of expertise include: posttraumatic stress disorder, reactive attachment disorder, and working with preschool children. I also treat mood disorders, anxiety disorders, grief and loss, children of divorce, anger management, and work with LGBT clients. In the event that I am incapacitated or die, a professional colleague of mine will be in touch with you to continue services or provide referrals for continued treatment.

About Counseling/Therapy

Counseling/therapy has several benefits. Some of these benefits include: improved functioning at work/school, less conflict with other people, or family members, and a general sense of well-being, etc. In order for counseling/therapy to be of benefit to you, it is important to attend sessions on a consistent and regular basis.

It also has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with me to be a source of strong feelings, some of them painful at times, or you may find yourself confused. It is important that you consider carefully whether these risks are worth the benefits of you in changing. Most people who take these risks find that counseling/therapy is helpful.

If you do violence to, threaten, verbally or physically, or harass myself or my family, I reserve the right to terminate you unilaterally and immediately from treatment.

Sessions last from 30 to 60 minutes. You will need to give 24 hours advance notice for cancelling a session. The only exception would be if you have fallen ill suddenly or you would endanger yourself by attempting to come (for example, driving on icy roads without proper tires). I reserve the right to terminate treatment for a missed session.

What to Expect:

The purpose of meeting with a counselor or therapist is to get help with issues or challenges in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a counselor or therapist about these problems. When we meet, we will discuss these issues or challenges. I will ask questions, listen to you, and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about these issues or challenges that are bothering you. For minors, sometimes these issues or challenges will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor or therapist. Privacy, also called confidentiality, is an important and necessary part of good counseling/therapy.

As a general rule, I will keep information you share with me in our session confidential, unless I have your written consent to disclose certain information. If you are under 18 years of age, I have to have your parent/guardian’s written consent to disclose certain information. There are, however, important exceptions to this rule that are important for you to understand before you share personal information with me in a counseling/therapy session. In some situations, I am required by law or by the guidelines of my profession to disclose information whether or not I have your permission. I have listed these situations below.

Confidentiality cannot be maintained when:

You tell me you plan to cause serious harm or death to yourself, and I believe you have the intent and ability to carry out this threat in the very near future. I must make sure that you are protected from harming yourself.

You tell me that you plan to cause serious harm or death to someone else who can be identified, and I believe you have the intent and ability to carry out this threat in the very near future. In this situation, I must inform the person whom you intend to harm.

You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, I will not disclose information without your written consent unless the court requires me. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Confidentiality with Minors

Communicating with Other Adults:

School: I will not share information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask your parent/guardian for written permission.

Doctors: Sometimes your doctor and I may need to work together: for example, if you need to take medication in addition to seeing a counselor or therapist. I will get your written permission and permission from your parent/guardian in advance to share information with your doctor.

Touch

Touch is a normal, healthy part of all parent-child interactions and is very important for the healthy development of all children. I use various kinds of touch in my treatment. I use touch that is playful and engaging. I use touch that is nurturing. I use touch to organize and modulate activities. I use touch to help or guide a child. A child who has been inappropriately or hurtfully touched in the past needs to relearn what gentle, fun, and appropriate touch feels like, and therefore learn that he/she is worthy of this kind of treatment. Also, children who may be extremely sensitive to touch need physical closeness and playfulness, therefore, treatment seeks ways to provide these experiences in ways that are tolerable for the child, and eventually to expand his/her tolerance for new sensory experiences. If a child is angry, deregulated or out of control in a session and has not responded to other efforts to calm him/her, I, with the assistance of the parent(s) stay and contain the child in some way; this may involve cradling the child on the lap of the adult, an arm around the child, or close soothing physical contact. If you are able, you the parent will contain your child with support from me. As soon as your child settles, the containment stops and the adult continues interacting with the child. Containment is done in reaction to the child’s deregulated behaviors; I will never provoke your child in order to contain him/her.

Professional Fees

My session for is $160 for the initial visit and $130 for subsequent visits. In addition to scheduled appointments, it is my practice to charge this amount on a prorated basis for other professional services you may require, such as report writing, telephone conversations that last more than 5 minutes, attendance at meetings or consultations with other professionals which you have authorized, preparation of records or treatment summaries, or the time required to perform any other service which you may request of me. If you become involved in litigation, which requires my participation, you will be expected to pay for the professional time required even if I am compelled to testify by another party. Because of the difficulty of legal involvement, I charge $260 per hour for preparation and attendance at any legal proceeding.

If your account is past 90 days and you have not made arrangements with me regarding payment, I will turn your account over to a collection agency. You will then be responsible for the cost of your account plus any collection fees.

Missed Appointments

If you fail to call 24 hours in advance to cancel your appointment, a $50 fee will be assessed. Additionally, I will contact you either via email or telephone to discuss this miss session.

Emergencies

If you have an emergency, you may call me 314-651-6679, you can call your psychiatrist, or you can call 911.

Follow-up

I like to follow-up with my clients after they have completed treatment or they have stopped seeing me. By signing this consent, you agrees to have me follow-up with you about a month and three months after services have stopped.

Complaints

If you are unhappy with what’s happening in counseling/therapy, I hope that you will talk about it with me so that I can respond to your concerns. I will take such concerns seriously, and with care and respect. If you believe that I have been unwilling to listen and respond and that I have behaved unethically, you can complain about my behavior to:

Missouri Division of Professional Regulation

3605 Missouri Boulevard

PO Box 1335

Jefferson City, MO 65102-1335

800-735-2466

1/8/13

Client Consent to Counseling/Therapy

I have read the Informed consent, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, understand it, and have no additional questions. I understand the limits of confidentiality required by law. I consent to the use of a diagnosis in billing, and to the release of that information and other information necessary to complete the billing process. I agree to undertake counseling/therapy with James Carroll, MA, LPC, NCC, CCMHC, MAC, CH, RPT-S. I know I can end counseling/therapy at any time I wish and that I can refuse any requests or suggestions.

Please INITIAL the following statements as verification that you fully understand your responsibilities:

_____ I understand I will not be called and reminded of upcoming appointments.

_____ I understand it is my responsibility to call 24 hours in advance if I am unable to make an appointment.

_____ I understand that failure to call 24 hours in advance will result in a $50 fee which I am obligated to pay.

_____ I understand regardless of my insurance, I am ultimately responsible to pay for all session fees and expenses incurred during treatment in a timely manner.

_____ I understand if I do not pay my fees in a timely manner, they will be turned over to a collection agency and I will also be responsible for collection cost.

Client’s Signature: ______Date: ______

Parent/Guardian’s Signature: ______Date: ______

Counselor’s Signature: ______Date: ______

1/8/13