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/The Healing Place
Consent, Confidentiality, and Policies StatementWelcome
The Healing Place is a private therapy practice that specializes in treating symptoms of trauma, anger, anxiety, and depression in children, adolescents, and adults. The Healing Place offers psychotherapeutic treatment to victims of abuse and witnesses to traumatic events. The Healing Place also assists parents in handling behavioral problems with children and adolescents such as acting out, disrespect, hyperactivity/attention-deficits, lack of focus/motivation, and non-compliance. The Healing Place utilizes a strengths-based and person-centered approach with a strong emphasis on adjusting the environment for optimal mental health and family functioning.
Confidentiality
Confidentiality is described as keeping private the information shared between a client and his/her therapist. Therapy sessions at The Healing Place are strictly confidential. Confidential information will not be released unless required or permitted by law. Possible exceptions to confidentiality include but are not limited to:
- Client/Parent/Guardian signs a release of information allowing the therapist to discuss confidential information with another party or parties;
- The therapist is mandated to report suspected abuse of a child, elderly person, or disabled person;
- The therapist is mandated to report the client’s disclosure of intent to harm self or others;
- The therapist is subpoenaed to testify in court or court-ordered to disclose confidential information; and/or
- The therapist is required by their professional codes of ethics to report sexual misconduct or unethical behavior of another mental health professional
For treatment of minors, risk-taking behavior that is considered detrimental to the safety of the minor or others will be shared with the minor’s parent(s) and/or guardian. Client/Parent/Guardian Initials: ______
Goals and Objectives
The goals and objectives of treatment will be specific to each client and will be discussed with you (and your child if appropriate) during the development of the client’s individualized treatment plan. Treatment plans will be reviewed and updated periodically with input from you (and your child). The Healing Place is committed to providing research-based, empirically supported treatment modalities and will recommend the most appropriate treatment modality for you (and your child) based on the individual needs presented.
Client/Parent/Guardian Initials: ______
Client Rights and Responsibilities
The length of time needed for healing and the amount of intervention required varies with everyone. An individual treatment plan will be completed for each client and will be discussed with you by your therapist. As a client, you are in complete control and may end your and/or your child’s counseling relationship at any time, though we do ask that you and/or your child participate in a termination session.
Client/Parent/Guardian Initials: ______
Therapy Process
Individual therapy appointments are 45-55 minutes in length and are usually scheduled once per week. Your therapist will meet with you regularly during your appointment time to discuss your progress, solicit feedback about the effectiveness of services, offer suggestions and/or address concerns. We encourage you to discuss with your therapist any approach, technique, or practice with which you have questions, concerns, or need clarification. In the case of child therapy, the parent(s)/caregiver(s) of the child have an instrumental role in the healing process. When you and your family receive clinical services at The Healing Place, your therapist will communicate regularly to discuss progress and treatment with his/her immediate supervisor. You and your family’s identifying information will not be disclosed during any consultation or supervision. Additionally, therapists at The Healing Place participate in the education of graduate-level students and professionals in fields related to therapeutic practice. Occasionally, therapists at The Healing Place may use deidentified information in the context case examples and scenarios purely for educational purposes. Healing Place assures you that clinical services will be rendered in a professional manner consistent with accepted legal and ethical standards.
Due to the nature of mental health treatment, The Healing Place cannot provide individual therapy services for clients who are simultaneously engaged in individual therapy treatment with another therapist.
Client/Parent/Guardian Initials: ______
Effects of Counseling/Risks of Therapy
For growth and progress to occur in therapy, participants may have to confront issues that cause sadness, anger, anxiety, or other uncomfortable feelings. Therapy is a process, and the success of therapy will in part be determined on the effort that you (and your child) are willing to put into the process. At any time, you may initiate a discussion of possible positive or negative effects of entering, not entering, continuing, or discontinuing counseling. While benefits are expected from counseling, specific results are not guaranteed. It is extremely important and helpful for you to inform your therapist, as soon as possible, of new problems that develop or changes in information that may have a positive or negative impact on your treatment (and/or that of your child).
Client/Parent/Guardian Initials: ______
Referrals
To assist in the recovery needs of your family, it may be necessary to refer you to other agencies or professionals. It is important to consider the referral recommendation as it may affect the ability for counseling to continue at The Healing Place. Your therapist will provide the referral, but you will be responsible for utilizing the referral. If your therapist believes it would be helpful to your family to talk to the other agency you will be asked to sign a consent form to release the information. Client/Parent/Guardian Initials: ______
Third Party Payers
Many clients choose to exercise their health insurance benefits to receive therapy services. In general, clients are responsible for paying the co-pay charge associated with exercising health insurance benefits and the insurance provider will remit payment for the remaining balance. Clients of The Healing Place are not responsible for paying more than the copay fee and balances unreimbursed by the health insurance provider will be waived. The therapist will explain the expected copay fee dependent upon the client’s insurance policy. By initialing below you authorize The Healing Place to collect your health insurance information and use it for reimbursement of services provided. Some insurance plans require obtaining authorization to receive mental health treatment. In these cases it is the sole responsibility of the client to obtain such authorization and if the client fails to do so prior to beginning services, clients may be held accountable for the therapist’s full fee for service. Client/Parent/Guardian Initials: ______
Relationship with the Therapist
The relationship that exists between a therapist and a client is professional rather than social. Therefore, contact with your therapist will only take place in the context of the provision of a professional service. The Healing Place asks that you do not offer gifts to your therapist, ask your therapist to write references for you, or ask your therapist to relate to you in any way other than the professional context of the counseling sessions. Your therapist is unable to have contact with you via social media sites. If your therapist sees you in public, she/he will protect your confidentiality by acknowledging you only if you approach your therapist first.A positive working relationship between the therapist and the client is very important for the success of the therapeutic process. If at any time you do not feel like the therapist is a good fit for your family, please notify your therapist so that we may refer you to another provider. Client/Parent/Guardian Initials: ______
Services to Non-Native English Speakers
Effective communication and mutual understanding is critical for successful therapy services. All therapists at The Healing Place are native English speakers, but may be fluent and offer therapy services in languages other than English. A therapist may offer services in a non-native language to the therapist. As a client you have the right to request a translator at any time to facilitate your therapy services and sessions. It is your responsibility as a client to inform your therapist if you do not fully understand the therapist or if you feel there is miscommunication due to a language barrier. Additionally, if you prefer to work with a therapist that is a native speaker of your language, you may at any time request a referral to a native-speakingclinician. Client/Parent/Guardian Initials: ______
Contact with Therapist
The therapist is often not immediately available by telephone but will check messages periodically throughout each day. Please note that The Healing Place is unable to track missed calls; therefore, you must leave a voice message if you would like your call to be returned. There may be times when the therapist is unable to return calls on the same day they are received. Most calls will be returned within one business day, and most calls received after hours and on weekends will be returned on the next business day. Client/Parent/Guardian Initials: ______
Email is only used for scheduling or changing appointments. Please refrain from discussing details of your situation in emails, as email is not a completely secure or confidential means of communication. Please note that if you choose to send emails to the therapist, they will become part of your therapy record or the therapy record for the child/adolescent. Client/Parent/Guardian Initials: ______
Therapist
Steven L. Parks is a Licensed Clinical Social Worker with years of practice experience. Steven has Master’s Degrees in Social Work and is licensed to practice by the Texas State Board of Social Work examiners (License# 57870). If you have questions or concerns about licensure you may contact the board on their website:
Steven L. Parks has received additional specialized training in these evidence-based modalities:
- Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)
- Play Therapy
- Parent-Child Interaction Therapy (PCIT)
Client/Parent/Guardian Initials: ______
Attendance Policy
In order to provide quality therapeutic services, regular attendance is necessary. Counseling services are by appointment only and are typically scheduled as reoccurring weekly appointments. You are responsible for consistently arriving on time for appointments and rescheduling if necessary. If you need to cancel or reschedule your appointment, please notify your therapist 48 hours prior to the appointment time. If you do NOT give your therapist at least 48 hours advanced notice about a cancellation you may be charged a cancellation fee equal to 50% of the cost of the cancelled session. Unfortunately, your therapist might have to cancel your appointment; if this happens you will receive notification as early as possible to reschedule or cancel.
You will be removed from the therapist’s schedule after either of the following:
1.Two consecutive missed appointments not cancelled prior to the appointment time
2.Three missed appointments in a month for any reason
It is the policy of The Healing Place that a parent or guardian must be on the premises when therapy services are being provided to a child/adolescent client. This policy is in place primarily to ensure the safety of the child/adolescent. Should there be a medical emergency, the staff of The Healing Place do not have the right to secure medical treatment. Additionally, a parent or guardian may need to join a session to provide information, assist in finding a solution to a problem, or to be a part of the therapeutic process. Please ensure that whoever transports your child/adolescent to sessions stays on the premises during the session.
Client/Parent/Guardian Initials: ______
Adult Consent for Treatment
I, ______,voluntarily consent to receive mental health assessment and treatment provided by a staff therapist at The Healing Place. I agree to participate in my treatment planning and therapy, and I understand that I may withdraw my participation in therapy at any time.
By signing this consent form, I acknowledge that I have read, understood, and agreed to the terms, conditions, and information contained within the form, and that I have been provided ample opportunities to ask questions and receive clarification of anything that I did not understand.
Client/Parent/Guardian’s Signature / DateTherapist’s Signature / Date
The Healing Place, 2060 E T.C. Jester; Suite 205, Houston, TX 77018 Phone 713-412-2729