Abiding Hope Christian Counseling, d.b.a.
Ginger Gray, LCSW
19115 FM 2252, Ste. 12
San Antonio, TX 78266
210-302-8576
www.abidinghopecc.com
Welcome to counseling. In order to insure our working relationship runs smoothly and that your questions have been answered, I have developed the following guide. Please read carefully, initial by each paragraph, and sign and date the bottom of the form.
QUALIFICATIONS:
I am licensed by the state of Texas as a Clinical Social Worker. I have a BA in Psychology from Southwest Texas University and a Masters Degree in Social Work from Our Lady of the Lake University. If you need to contact the licensing board that information is posted in the waiting area or is available by request.
SERVICES AVAILABLE:
Individual, couples, and family therapy is available. Although every effort is made to be a positive influence, there are no guarantees of happy outcomes in therapy. Please be informed that marital therapy can lead to divorce. In addition, be aware that the process of therapy takes time and things often appear worse before they get better.
OFFICE HOURS AND TELEPHONE CONTACT:
I see clients Sunday 9am through 6:30pm and Monday and Tuesday 8:30am through 6:30pm.and Wednesdays 9:30am through 3:30pm. Occasionally, at my discretion, I will schedule appointments on different days or times. This is always the exception rather than the rule.
If you need to contact me, please call my confidential voice mail. Feel free to leave any urgent message you have and I will make every effort to get back to you as soon as possible and no later than 48 hours. I am with clients nearly every hour I am in the office, therefore I rarely return phone calls during the day. Calls received on Friday, Saturday or a holiday will be returned the following workday. You may contact me via e-mail, but the same 48 hour rules apply. If I don’t respond to an e-mail, you can assume I didn’t get it.
You will be charged for telephone calls lasting longer than five minutes. When I am out of the office for an extended period of time, I will leave the name and number of a colleague you can contact.
I am not available for an emergency. In case of an emergency, please contact your psychiatrist, then call 911 or go to your nearest emergency room. Later, leave a message on my voice mail and I will return your call the next workday.
SESSION LENGTH:
Sessions are approximately 50 minutes in length. The exception is the first session, which can last 1-½ hours and is prorated accordingly. If you are late, you are charged for the full therapy hour, even though you may not receive the full 50 minutes. If I am late, you receive your full therapy hour.
OTHER PRACTITIONERS:
There are several independent practitioners at this office location. None is liable for the practices of the other. If you ever have a serious concern regarding myself or another practitioner, please discuss it with me. Your concerns will be addressed and you will be given information on how to contact our various licensing boards.
If I should ever become incapacitated and become unable to care for your records, Kelly Zentner, 210-545-2111 will have access to retrieve your records. She will not be taking over the case but she will help you find someone who can help.
CONFIDENTIALITY:
Confidentiality is an important component of therapy. All therapy sessions are strictly confidential as mandated by law and the social work code of ethics, except where state laws require reporting. Those exceptions include: reasonable suspicion of the emotional, physical or sexual abuse of children, the handicapped or the elderly, where the client presents a serious danger of harm to himself or to others, in child custody cases, and in case of a subpoena by a court of law. If you intend to become involved in a lawsuit and want to involve my records, please notify me as soon as possible so I can review the risks to confidentiality with you. In addition, information may be released when you sign a release of information for your insurance company, to speak to your doctor or when there is a need for other professional consultation.
People who use their insurance to pay for psychotherapy waive some of their rights to confidentiality. When you use your insurance, a psychiatric diagnosis must be assigned and transmitted to your insurance company, detailed clinical information often must be provided by your therapist, and in the case of “in network” benefits, total access to patient files often must be provided to insurance company employees. Further, insurance companies often attempt to influence the methods or course of treatment to save money. That means treatment decisions are taken away from you and your therapist, the two people in the best position to make such decisions. Finally, psychiatric diagnoses may affect your ability to obtain future health or life insurance at a reasonable cost. There is not a way to ensure that confidential information will be treated as private once it is transmitted to an insurance company or attorney’s office. For example, employers sometimes are able to obtain personal information from insurance records.
In order to protect your confidentiality, to provide ethical treatment, and to reduce administrative costs, I encourage you to pay out-of-pocket for your therapy. You will always receive a receipt which can be used to bill your insurance for “out of network” reimbursement or for tax purposes.
Please understand that contact outside of face-to-face sessions is done on cordless and cellular phones. Therefore, conversations via these means have limited privacy. Any e-mail contact also has limited privacy.
FINANCIAL AGREEMENT AND CANCELLATIONS:
Fees are $140.00 for the initial session if it is 50 minutes in length, $175 for the initial session if it is 90 minutes in length and $110 for each 50 minute session thereafter. Letters, legal documentation, time in court, reports and collateral contacts are also assessed a fee. My fee for any court related time is double my hourly amount or $220 per hour. It will be charged to your credit card on file (see below). Cash, checks, MasterCard and Visa is accepted for all services.
Payment in full or your co-pay is expected at the time of each session. We can bill your insurance as a courtesy. Your insurance will not pay for missed appointment fees and you are responsible for those fees assessed as outlined below. You may be turned into a collection agency to collect non-payment. You can be legally terminated as a client for non-payment of fees. I will give you several referrals when I discharge you for non-payment of any fees.
My fees are based on the time I commit to work with you in sessions. To keep client fees reasonable cancellations with less than 24 hours and no shows will result in a fee of $50. Every client must keep a credit card on file or leave an undated check in the amount of fifty dollars to cover this fee. This is not optional. The check will be returned upon termination of services. Your signature below indicates your promise not to dispute charges (“charge back”) for sessions you have received or no show/cancellation fees. In addition, your signature further authorizes Ginger Gray, LCSW or her employee(s) to disclose information about your attendance/cancellation to your credit card issuer if you dispute a charge. You must cancel this agreement in writing.
Cancellations for Sunday or Monday, must be made no later than Thursday evening to avoid a fee. Cancellations must be made via my voice mail. I do not have e-mail access outside office hours, therefore cancellations via e-mail are not acceptable under any circumstance.
RIGHT TO ACCESS RECORDS:
Adult clients, legal guardians of minors, including managing and possessory conservators, have the right to access the records of the services provided to them. However, the therapist has the right to withhold information from a client if the therapist determines it is in the best interest of the client.
TREATMENT OF MINORS:
Minors can be treated for emotional, physical, sexual abuse or for alcohol and drug related issues without consent. Otherwise, treatment of children less than 18 years of age will be provided only with the consent of the legal guardian. By signing this consent form the signor acknowledges that he or she is the legal guardian of any minor presented for treatment. Custodial agreements must be in writing and must be attached to this paperwork.
NON CLIENT CHILDREN:
Children under the age of ten not receiving services are not allowed to be unattended in the outer office while an adult client is receiving services in the inner office. Any children left unattended at any time must have a specific agreement with the therapist made when the appointment was scheduled. This is both a liability and legal issue.
GIFTS, DUAL RELATIONSHIPS AND PHYSICAL TOUCH:
The Social Work Code of Conduct does not allow social workers to receive gifts valued at more than $25.00 and gifts given are usually limited to a natural time of gift-giving such as termination of services or Christmas. Beautiful cards with a heartfelt message are more appropriate than gifts. The Social Work Code of Conduct also prohibits a social worker from having more than one relationship with a client. Therefore, once you are a client, you cannot become a friend, involved in any business together, including buying or selling of products or any other relationship other than client-therapist. We may inadvertently come in contact with each other outside of the office setting. It is up to the client to determine whether to acknowledge the therapist in any way at that time.
The policy of this office is that physical touch is not a part of the therapeutic intervention and is not used as such during counseling sessions.
CELL PHONES:
The waiting area has been designed to encourage tranquility. Therefore, use of cell phones in the waiting area is not permitted. Please respect this policy and step outside if you need to use your cell phone. Turn your cell phone off or to vibrate when entering the office.
TERMINATION OF SERVICES:
While therapy may vastly improve the quality of your life, it is also an expensive process. The duration of therapy is affected by the nature of your concerns and your goals. It is important that you feel that you are benefiting from treatment. It is my practice to evaluate with you regularly whether there is a continued need for services. If at any time you feel that you are not getting what you want or need out of therapy, or if your financial situation changes, I urge you to discuss it with me so that we can find a solution for your concerns.
You may take a break or end therapy at any time. However, I have found it is most helpful to the client to make that announcement at the beginning of a session and prior to the last session. It is not appropriate or healthy to end therapy with a cancelled appointment via telephone.
In the event of child custody disputes, therapy will be terminated immediately with three references. I do not serve anyone’s best interests by being in court. It is potentially harmful to you and a disservice to my other clients. You can also be legally be terminated for non compliance of treatment plans including remaining sober, doing homework assignments, etc.
My signature indicates my understanding of the office policies and my agreement to abide by the items outlined therein. I will receive a copy of this agreement at the end of the first session.
Client Signature Date
Client #2 (or parent/guardian if a minor) Signature Date
Signature of Therapist Date
Abiding Hope Christian Counseling, d.b.a
Ginger Gray, LCSW
19115 FM 2252 Ste. 12
San Antonio, Tx 78266
Voice mail: 302-8576
www.abidinghopecc.com
PLEASE PRINT
Are you comfortable with the therapist praying at the end of each session?_____
Do you use alcohol or other drugs on a regular basis and if so, how often?______
Brief MAST
1. Do you feel you are a normal drinker? Yes_____No_____
2. Do friends or relatives think you are a normal drinker? Yes_____No_____
3. Have you ever attended a meeting of Alcoholics Anonymous(AA)? Yes_____No_____
4. Have you ever lost friends or girlfriends/boyfriends because of drinking? Yes_____No____
5. Have you ever gotten into trouble because of drinking? Yes_____No____
6. Have you ever neglected your obligations, your family, or your work for two or more days in a row because of drinking? Yes____No_____
7. Have you ever had delirium tremors (DT’s), severe shaking, heard voices or seen things that weren’t there after heavy drinking? Yes____No_____
8. Have you ever gone to anyone for help about your drinking? Yes____No_____
9. Have you ever been in a hospital because of drinking? Yes____No_____
10. Have you ever been arrested for drunk driving or driving after drinking? Yes____No_____
What are your ambitions/goals? ______
______