Roman & Sokolowski Counseling, PLLC

Roman & Sokolowski Counseling, PLLC

1200 Division Street, Suite 203C  Nashville, TN 37203

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INFORMED CONSENT

Entering into a therapeutic relationship with a counseling professional requires an establishment of trust. When you begin therapy, you are committing your time, money and emotional energy and it is important to fully understand what that commitment will entail. Included below is a summary of the policies and processes that guide your work at Roman & Sokolowski Counseling, PLLC (RSC) and with me as your therapist.

Professional Background & Services – Mary Ann Sokolowski M Ed, LPC-MHSP

I am a Licensed Professional Counselor with the Mental Health Service Provider designation (LPC-MHSP), a, and hold a Master’s of Education in Professional Counseling (M.Ed.). I am specially trained in EMDR, Trauma-Focused Cognitive Behavioral Therapy and DBT. I have provided individual counseling for adolescents, and adults and groups in agency, private organizations, and private practice for the past four years.

I use an eclectic approach to counseling, integrating cognitive-behavioral therapy, mindfulness, acceptance and rational emotive behavior therapy, self-compassion, EMDR, positive psychology, narrative therapy and person-centered therapy. I operate from the belief that you have the capacity for personal growth and hold within yourself the resources for change and self-understanding. I believe that you are not defined by your problem, your trauma or your mental health diagnosis, and I pursue the goal of empowering you to transform your inner narrative in order to rediscover purpose and meaning. I am trained in the full spectrum of mental health concerns, but my practice focuses primarily on anxiety, depression, self-harm, trauma, sexual assault, and life transitions.

I am available for counseling appointments Tuesday- Thursday from 9:00am to 7:00pm. You can make an appointment by calling 423-744-4119 between 9am and 5pm. If I am unavailable to take your call, please leave a confidential message so that I can return your call within 24 hours. You can also reach me by email at If you are experiencing a mental health emergency and cannot reach me, please go directly to your nearest emergency room for assistance or call the Crisis Help Line at 615-244-7444.

In the case of my death, incapacitation or termination of practice,Amanda Roman, LPC-MHSP, co-owner of RSC, will assume responsibility for the management of my clients’ therapy and records.

Confidentiality

Tennessee State law and ethical requirements of the State Board indicate that what we discuss in our private counseling sessions is privileged communication, meaning that you as the client control the release of this information to a third party. This means that except for certain specific exceptions described below, I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your written permission. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. If it would benefit you in your counseling progress, I may ask you to sign a release of information to allow me to discuss information with your primary healthcare professional or other key providers in your life (e.g., a psychiatrist or a previous counselor). You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA), which ensures the confidentiality of all electronic transmission of information about you.

There are several limits to confidentiality that involve the required release of information in order to keep you and/or others safe from harm. These limits include:

1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

2. If I have good reason to believe that you are physically or sexually abusing, inflicting psychological harm or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform the Department of Children’s Services or the police within 48 hours.

• If you are legally an adult and you tell me you are having sex with a minor more than four years younger than you, or if you are a teacher, coach or other authority figure, and you tell me you are having sex with a minor of any age, I must also report this to the Department of Children’s Services.

3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police, the county crisis team or someone who can ensure your safety. I would first explore all other options with you before I took this step.

4. If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the therapist‐patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in, or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

You should be aware that I co-own RSCwith Amanda Roman, LPC-MHSP, another mental health professional. Ms. Romanand I will need to share protected information with each other for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All mental health professionals are bound by the same rules of confidentiality.

I also consult periodically with various experts in specific fields of mental health so that I can better serve my clients. If I consult on my work with you, I will not use your name or any information that can identify you. If there is any reason to believe you might know one of these professionals, I will tell you their name so you have the option to request I do not consult with them regarding your care.

If applicable, see addendums on Policy for Minors in Counseling, Policy for Couples Counseling, and Policy for Group Counseling for additional confidentiality limits.

Communication Policy

If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you will be printed out and kept in your clinical record. I request that email only be used for scheduling and business purposes. Please do not email content related to counseling sessions or issues going on in your life that are best addressed in the counseling appointment.

I do not accept text messaging as a form of communication from clients. Text messages can be intercepted, stored on both the sender’s and receiver’s device and later read by others, read by phone providers, or sent to non-intended individuals. They may not be received due to technological glitches, lack of service or lack of access to a cell phone. Texting is an inappropriate medium to discuss counseling issues and concerns.

If you have a psychiatric emergency that arises between sessions, please call me between 9:00a and 5:00p. If it is after hours or you cannot reach me, please call the Crisis Help Line at 615-244-7444 or go directly to your nearest emergency room. If you have a concern or are having difficulty with a counseling issue between sessions, please write it down and wait until our next scheduled session to discuss it.

Social Media Policy

RSC has professional accounts on Facebook, Pinterest and Instagram in order to share information and practice updates with other social media users. We recommend that you only follow these professional sites if you are comfortable with your name and information being connected to our counseling practice. We do not require any clients to follow our professional accounts, and we do not request testimonials, ratings or endorsements from clients on these sites. These sites are not places for personal discussion concerning therapeutic issues, either through wall postings or private messages.

Neither I nor RSC will follow or contact any former or current clients on any social networking site (Facebook, LinkedIn, Twitter, blogs, or other apps/websites). Adding clients as friends on these sites can compromise your confidentiality and the therapeutic relationship. If there is content you wish to share from your online life, please bring it into sessions where it can be explored with your counselor.

I will not search for you on Google or Facebook or any other search engine or social media account. The only exception would be in times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone or email), there might be an instance in which using a search engine becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will discuss it with you when we next meet.

Court Policy

I am not a certified Custody Evaluator or an Expert Witness, as defined by the legal system. As a mental health counselor, I am not permitted to make any judgments on custody.

I do not testify unless required by a court order. In the case that I would be subpoenaed to court or involved in any legal matter, the client will be charged a fee of $150 an hour. This includes note taking, phone calls, writing case summaries, time to and from court, etc.

If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the therapist‐patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in, or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

Benefits and Risks of Counseling

Counseling has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of therapy often requires discussing the unpleasant aspects of your life. Approaching feelings or thoughts you have tried not to think about for a long time may be painful. It is not unusual for them to worsen before they get better. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. It is important that you consider these risks carefully. I am available to discuss any of your problems or possible side effects of our work together.

Counseling has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Successful counseling requires a very active effort on your part. It can be of great benefit to a client who fully commits to being open and honest in the counseling relationship and who comes to the table with their own personal goals for counseling. Ultimately, you are responsible for your own growth.

The Counseling Process

Establishment of the Counseling Relationship

The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what the work might include. At that point, both of us will discuss your treatment goals and create an initial treatment plan. We may discuss additional resources or activities that added to counseling may help further your change and growth. These may include referrals to a PCP for medication evaluation, directions for a specific activity plan of exercise, referrals to a nutritionist, etc. Wellness comes from whole body health that should include an emphasis on mind, body and spirit. You should evaluate this information and make your own assessment about whether you feel comfortable working with me as your therapist. We will then create a plan together that is individualized to your own goals and desires for counseling outcomes.

You have the right and responsibility to decide whether the proposed treatment plan will provide you with the treatment that you want. You have the right to ask questions about anything that happens in therapy. At any point during treatment you are encouraged to let me know if something does not feel right, or if you want something else from treatment. I am always willing to discuss how and why I have decided to do what I am doing and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I am not the right therapist for you. Your input into the process of therapy, no matter how hard to put into words, is very important.

You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. If you are late, we will end on time and not run over into the next person's session.

I expect you to work outside of our time in session together in order to enhance the effectiveness of therapy. The work will be tailored to your needs and personality. Some examples include journaling, reading, practicing a new skill, etc. Completing work outside of session is related to a host of positive outcomes, including more improvement and quicker progress.

Termination of the Counseling Relationship

The process of counseling must eventually come to an end. Ideally, termination occurs once you and I agree that the treatment goals have been met. You have the right to stop treatment at any time and for any reason. You will be the one who decides therapy will end, with a few exceptions:

1. If I believe I am not able to help you, because of the kind of problem you have or because my training and skills are not appropriate, you will be informed of this fact and referred to another therapist who may meet your needs.

2. If you verbally or physically attack, threaten, or harass me, the office, any of the counselors or significant others, I reserve the right to terminate you unilaterally and immediately from treatment. If you are terminated from therapy, I will offer you referrals to other sources of care but cannot guarantee they will accept you for therapy.

4. If you fail to participate in therapy or comply with treatment recommendations, I will provide you with appropriate referrals to other sources of care.

5. If I do not have contact or communication from you for a period of 30days, I will assume that you no longer intend to remain active in this therapeutic relationship, and your record will be closed.

Review & Access to Records

The standards of the profession require that RSC keep client records. You are entitled to receive a copy of your record or your clinician can prepare a summary for you. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your record, you must supply a written request, and it is recommended that you review the record with me so that I can explain the record to you and answer any questions you may have. RSC will comply with all written requests for records within 10 business days from receipt of request and will charge an administrative/copying fee of $75.

Please feel free to discuss with me any of the policies and processes outlined above. It is important that you clearly understand your rights and responsibilities when entering into a counseling relationship.

______(Initial)I acknowledge that I have read the Informed Consent document in its entirety.

______(initialI acknowledge that my counselor reviewed the policies listed in the Informed Consent document with me and that I have addressed any questions to my therapist regarding the policies.

______(initial)I acknowledge that I have received a copy of the Informed Consent document.

______(initial)I acknowledge that I have received a copy of the Notice of Privacy Practices for Protected Health Information document.

______(initial) I give consent to my therapist, Mary Ann Sokolowski LPC_MHSP, to provide clinical treatment in the context of the counseling relationship.

Upon my signature below, I acknowledge that I understand and agree to these policies and processes.

Client Signature Date

Counselor SignatureDate

Informed Consent, page 1 of 1Date Revised, 3-Dec-18