Gordon S. Leith, MA, LPC, MAC, SAP
8930 Four Winds
San Antonio, TX 78239
COUNSELOR-CLIENT CONTRACT
INFORMATION AND CONSENT
Qualifications/Experience
I am pleased you have selected me for your counseling needs. This document is designed to inform you about my background and to ensure that you understand our professional relationship.
I have a M.A. degree in Counseling (Mental Health & Substance Abuse Treatment) from St. Mary’s University. I am licensed as a LPC by the state of Texas. I hold certifications as a Master Addiction Counselor (MAC) by the National Association of Addiction Counselors (NAADAC) and a Substance Abuse Professional (SAP) in accordance of the guidelines set by the United States Department of Transportation. My counseling is limited to individuals, couples, families and group counseling of adults, adolescents and children.
Nature of Counseling:
I accept only clients who I believe have the capacity to resolve their own problems with my assistance. I believe that as people become more accepting of themselves, they are more capable of finding happiness and contentment in their lives. However, self-awareness and self-acceptance are goals that take time to achieve. Some clients need only a few counseling sessions to achieve these goals, while others may require months or even years of counseling. You may choose to discontinue the counseling relationship at any point. I will be supportive of that decisioin. If counseling is successful, you should be able to face life’s challenges in the future without my support or intervention.
Although our sessions may be very intimate emotionally and psychologically, it is important for you to realize that we have a professional relationship rather than a personal one. Our contact will be limited to the paid sessions you have with me. Please do not invite me to social gatherings, offer gifts, or ask me to relate to you in any way other than in the professional context of our counseling sessions. You will be best served if our relationship remains strictly professional and if our sessions concentrate exclusively on your concerns. You will learn a great deal about me as we work together during your counseling experience. However, it is important for you to remember that you are experiencing me only in my professional role.
Fees, Cancellation and Insurance Reimbursement:
(The fee for sessions will be $______each.) In return for a fee of $______per individual session; $______per couple/family session; and/or $______per group session, I agree to provide services for you. The fee for each session will be due and must be paid at the conclusion of each session. Cash or personal checks are acceptable for payment. In the event that you will not be able to keep an appointment, you must notify me 24 hours in advance. If I do not receive such advance notice, you will be responsible for paying for the session you missed.
Some health insurance companies will reimburse clients for my counseling services and some will not. In addition, most will require that I diagnose your mental health condition and indicate you have an “illness” before they will agree to reimbursement. Any diagnosis will become part of your permanent insurance records.
If you wish to seek reimbursement for any services from your health insurance company, I will be happy to complete any forms related to your reimbursement. Insurance companies that do not reimburse for counselors usually require that a standard amount ( a “deductible” or “co-pay”) is paid by you and then usually a percentage of my fee is reimbursable. You should contact a company representative to determine whether your insurance company will reimburse for counseling and what schedule of reimbursement is used.
Records and Confidentiality:
All of our communication becomes part of the clinical record, which is accessible to you on request. I will keep confident anything you say to me, with the following exceptions: (a) you reveal to me any incidence of child or elder abuse; (b) I determine that you are a danger to yourself or others; or (c) I am ordered by a court to disclose information.
By signing below you are indicating that you have read and understand this statement, and/or that any questions you had about this statement have been answered to your satisfaction.
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(Counselor’s Signature) (Date) (Client’s Signature) ( Date)