DillonInternational InformationandPolicyStatement forCounseling
Pleasereadthefollowingimportantinformation.If youhaveanyquestions,youmaydiscussthemwithyourcounselor.
Confidentiality:FederalHIPAAandstatelawsrequirethatwhatyousayina counselingrelationshipisprotectedby law.Thelegalexceptionstoconfidentialityinclude(1)revealingintentto harmyourselfor someoneelse,(2) suspected childorelderabuseor neglectand(3)instanceswherethecourtor governmentsubpoenarecords.Itisimpossibleto protecttheconfidentialityofinformationthatis submittedelectronically.
TheTherapeuticProcess,BenefitsandRisks: Weendeavortoworktogethertoreachpersonalgoals,attainresolution ofconflicts,relievesymptoms,resolvepastwoundsandachievepersonalgrowth.Thismayincludeevaluations, psychotherapy,counselingandothermodesoftreatmenttailoredtoyourneeds.
Inthepursuitofthesechanges,theremaybetimesofunpleasantemotionsanddisruptionsinotherareasoflife.Thisisa normalpartofchangeandyoushouldbeawareoftheserisksbefore youbegincounseling.Wedo notuseemail exchangesasa partofcounseling.Atanytimeyouhavea righttoanexplanationofthecounselingplanandatanytime youmaydeclinetreatment.
Lengthof Treatment:Counselingwillendwhenyouandyourcounselordecidethat yourpersonalgoalshavebeen reached.Youhavetherighttoendortakea breakfromcounselingatanytime.
Appointments:Appointmentsarescheduledweeklyoreveryother week.Thestandardpracticeisto setupyournext appointmentduringeachappointment.Appointmentsare50 minutesinlength.
Cancellations:If youneedtocancelanappointment,24 hournoticeisrequired.
Fees:Thecurrentfeeis$40.00anhour.All fees must be paid prior to the session.Therewillbea $20.00chargeforeach “non-sufficientfunds”checkreturn. If a payment plan is agreed upon, the maximum account balance permitted is $120.00. Oncethisbalanceisreached,counselingmaybediscontinueduntil furtherpaymentisreceived.Professionaltimespentoutsideofthetelephoneconsultation,including,butnotlimitedto between-sessionphonecallsoremailexchanges,reportwritingandreadingorreviewingdocuments,willbebilledona proratedbasisroundeduptothe nearesttenth ofanhour.If wearerequiredtoattendmeetingsoutsideofouroffices,you willalsopayfortravelingtimeandmileage.
EmergenciesandAfterHourCare: Ourgeneralphilosophyisthatclientsareassumedtobe self-responsiblefor emergenciesbycalling911orgoingtotheemergencyroom.Wedonotprovidecrisisoremergencyservices.Youmay leavea voice mail messageduringtheweek.If youneedrecurringphonecontactasa regularadditiontoyourtherapy, thefeeis$10.00per5-minuteperiod.
Court Testimony and Custody Evaluations: We make every effort to maintain confidentiality and therefore do not testify in court or release documentation regarding custody, divorce action or other legal matters. If we are subpoenaed, you agree to pay all costs and this may result in termination of services.
Yoursignatureindicatesyouhavereadtheinformation,youwillabidebythetermsofour professionalrelationshipand youhavebeenprovidedtheHIPAANoticeofPrivacyPractices.
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