27 Gamecock Ave. Suite #202 Charleston, SC 29407

The Center 4 Families, LLC

Helen Elliott Wheeler, M.Ed. LPC

(843) 763-5837; Fax (803)753-0134

Informed Consent for Couples Counseling

What can I expect? Individuals and couples seeking to enter a counseling relationship can expect to gain some benefits from the process. These benefits often include: lessening of unpleasant feelings and/or destructive lifestyle choices. Occasionally during the process of counseling, some of those feelings temporarily increase. That can be considered normal, but if they do not decrease, please notify me. Please remember that we have a strictly professional relationship which does not include socialization outside of the office, nor can I receive gifts from clients. Sexual contact is always considered inappropriate and can be reported to my state licensure board.

“No Secrets” Policy. This written policy is intended to inform you, the participants in counseling, that when I agree to treat a couple or a family, Mrs. Wheeler considers the couple or family (the treatment unit)to be the client. For instance, if there is a request for treatment records of the couple or family, she will seek authorization of all members of the treatment unit before I release confidential information to third parties. Also, if her records are subpoenaed, she will assert the counselor/client privilege on behalf of the client (treatment unit).

During the course of my work with a couple or family, Mrs. Wheeler may see a smaller part of the treatment unit (e.g. an individual, a child, etc.) for one or more sessions. These sessions should be seen by you as a part of the work she is doing with the family or the couple, unless otherwise indicated. If you are involved in one or more of such sessions with her, please understand that generally these sessions are confidential in the sense that she will not release any confidential information to a third party unless required by law to do so or unless she has your written authorization,. In fact, since those sessions can and should be considered a part of the treatment of the couple or family. She would also seek the authorization of the other individuals in the treatment unit before releasing confidential information to a third party.

However, Mrs. Wheeler may need to share information learned in an individual session (or a session with only a part of the treatment unit being present) with the entire treatment unit—that is, the family or the couple, if she is to effectively serve the unit being treated. She will use her best judgment as to whether, when, and to what extent she will make disclosures. Thus, if you feel necessary to talk about matters that you absolutely want to be shared with no on, you might want to consult with an individual therapist who can treat you individually.

This “no secrets” policy is intended to allow Mrs. Wheeler to continue to treat the couple or family by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple or the family. If she is not free to exercise her clinical judgment regarding the need to bring this information to the family or the couple during therapy, she might be placed in a situation where she will have to terminate treatment of the couple of the family. This policy is intended to prevent the need for such termination.

When a couple comes in for counseling, the couple is designated as the client which carries with it different requirements. If you are receiving marital counseling and end up proceeding through to divorce, understand that I will be unable to provide you with affidavits and or session notes without the express written consent of both parties. Differing roles, counseling goals and confidentiality and consent issues are affected by these dynamics.

Confidentiality and privilege. Information revealed by you during therapy will be kept strictly confidential and will not be revealed except by your written permission (with the exceptions noted above). With couples and family counseling, there might be, in addition to the circumstances listed below, times when I do not guarantee confidentiality. I will attempt to keep confidentiality between family members except when maintaining the secret will likely lead to grave and serious harm to a family member. Release of information to third parties requires a signed permission form.

You should know that there are additional circumstances in which I am required by law to reveal information obtained during the process without your permission. In these cases, I might not be required to inform you of my actions in this regard. These situations are:

Threat of bodily harm to self or others
A court order issued by a judge requiring me to testify to what we have spoken about.
In the cases of child or elder abuse or neglect

In case of emergencies. You may try calling me on the number listed above. If you are unable to contact me or I am otherwise unavailable, please call 911 or go directly to the nearest emergency room. If you need someone to speak to, you may also dial 211 from a landline (or 744-HELP from a cell phone) for access to the local Hotline help and referral service.

Clients’ statement of understanding. We understand by signing below that we are giving consent to evaluation and treatment by the above counselor. There is a different standard for confidentiality during couples’ counseling. I also understand that there is no professional relationship stated or implied with others sharing office space at the above address.

Insurance companies. We will be glad to work with you in filing your insurance claims. In the case of third party payers (insurance companies) I understand that the company has the right to review my treatment records as part of the quality control or to determine payment. I also understand that if the insurance company does not pay, I will be responsible for payment for services. Please note that when you check with your insurance company for coverage, you must specify that the counseling will be for couple/family counseling. Many insurance plans do not cover this kind of service. Any pre-authorizations should be done ahead of time, if possible. Payment will be expected for co-pays and deductibles at the time of service; The Center for Families is not set up for billing.

There will be a $25.00 charge in the case of a returned check. I understand that there will be no further appointments scheduled until the check is retrieved by cash or credit card for amount of check plus $25 service fee.

Scheduling and Fees. By initialing below, I acknowledge that I have read and accept these terms.

______Individual sessions are normally scheduled for 50 minutes. Fee for regular session is $100. At the first session, you can expect it might take longer and first session fees are $125.

______Family or couples sessions can be arranged for 80-90 minutes for $125.

______For emergency and crisis situations, we can arrange marathon sessions of several times per week for $150.

______In the case of extraordinarily difficult cases or in cases where the client(s) live a distance out of Charleston, we can arrange for intensive counseling time of 3-4 hours in evenings or on weekends for $400.

______I understand that I can arrange phone therapy after hours or between sessions for $25. This is not billable to insurance companies.

______If I have been asked to correspond by e-mail, I understand that if it takes longer than 15 minutes, I will be charged $25. I also understand that it will be necessary to sign a consent to use email permission form. This is not billable to insurance companies.

______I will be responsible for any deductibles, co-payments or other expenses not covered by my insurance company at the time of the visit. If a claim is denied, I understand that I will be responsible for paying the ‘customary and prevailing charge’ for non-covered charges.

______When I have an appointment scheduled, that time has been set aside for me. If I am late, I understand that I will forfeit that time.

______If I request Mrs. Wheeler to appear in court, the fee for that appearance will be $200. per hour plus travel time. This service is not billable to insurance companies.

______I understand that “phone therapy” is not usually effective and that I will be charged for any phone conversations that take place in excess of 15 minutes.

______Likewise, when I have an appointment and am unable to attend, I will make every effort to notify the counselor as soon as I can. If I do not call and do not show, I will have to pay a $25.00 session charge. That cannot be filed with the insurance companies.

Payment options. You may pay with Visa, Mastercard, cash or check. If you would like to authorize our office to process your recurring charges, please request to sign a Pre-Authorized Health Care Form.

Professional Training Mrs. Wheeler graduated with Distinction from the Citadel with a degree in clinical counseling. She is licensed by the state of South Carolina as a Professional Counselor and is certified by the state as a school teacher. In addition, she has received specialized training in handling high conflict divorces and is a Family Court Mediator.

Code of Ethics and membership: SC Counseling Association, American Association of Christian Counselors, Association of Marriage and Family Ministries

______

Husband’s signature Date Wife’s signature

______

Counselor’s signature