INFORMATION, AUTHORIZATION & CONSENT TO TREATMENT
I am very pleased that you have selected me to be your therapist, and I am sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment. Although providing this document is part of an ethical obligation to my profession, more importantly, it is part of my commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with me is a collaborative one, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.
Background Information
The following information regarding my educational background and experience as a therapist is an ethical requirement of my profession. If you have any questions, please feel free to ask.
I have been practicing as a psychotherapist for 23 years, supporting individuals in their journey toward deep healing and transformation. I hold a Bachelor’s degree in Ecology (1997) and Psychology (1998) from the University of Georgia, as well as a Master’s in Social Work (2002) from UGA, following the Licensed Clinical Social Work (LCSW) track. I am a Licensed Clinical Social Worker (License #0003573) and have completed Level 2 training in the Internal Family Systems (IFS) model. I am also certified in Nonviolent Communication (NVC). By combining these tools with my expertise in eco-psychology and deep nature connection, I bring a holistic and intuitive approach to healing. My integrative methods help clients shift old patterns, fostering greater connection, health, and vitality in their lives.
Theoretical Views & Client Participation
It is my belief that as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. As a client, you are in complete control, and you may end your relationship with me at any point.
In order for therapy to be most successful, it is important for you to take an active role. This means working on the things you and I talk about both during and between sessions. This also means avoiding any mind-altering substances like alcohol or non-prescription drugs for at least eight hours prior to your therapy sessions. Generally, the more of yourself you are willing to invest, the greater the return.
Furthermore, it is my policy to only see clients who I believe have the capacity to resolve their own problems with my assistance. It is my intention to empower you in your growth process to the degree that you are capable of facing life’s challenges in the future without me. I also don’t believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, I will direct you to other resources that willbe of assistance to you. Your personal development is my number one priority. I encourage you to let me know if you feel that terminating therapy or transferring to another therapist is necessary at any time. My goal is to facilitate healing and growth, and I am very committed to helping you in whatever way seems to produce maximum benefit. I truly hope we can talk about any of these decisions. If at any point you are unable to keep your appointments or I don't hear from you for one month, I will need to close your chart. However, as long as I still have space in my schedule, reopening your chart and resuming treatment is always an option.
Confidentiality & Records
Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you direct me to tell someone else, and you sign a “Release of Information” form; (2) I determine that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) I am ordered by a judge to disclose information. In the latter case, my license does provide me with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a therapist. Most states have a very good track record in respecting this legal right. If, for some unusual reason, a judge was to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say confidential. Since I practice in more than one state, I will make sure to provide you with any additional information related to confidentiality in the state where you are at the time of services as necessary.
Please note that in couples counseling, I do not agree to keep secrets. Information revealed in any context may be discussed with either partner.
Professional Relationship
Our relationship must be different from most other relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other way, we would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the client’s interests, and then the client’s (your) interests might not be put first. To offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature.
Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it is useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.
Additionally, since therapists are required to keep the identity of their clients confidential, for your confidentiality, I will not address you in public unless you speak to me first. I must also decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In sum, it is my ethical duty as a therapist to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way; they are strictly for your long-term protection.
Ethics, Client Welfare & Safety
I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the Association of Social Workers. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I will provide you with information to contact the professional licensing board that governs my profession.
Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so. However, with your participation, we will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is my intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.
Additionally, at times, people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn’t sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and I are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.
For the safety of all my clients, their accompanying family members, children, other therapists in the building, and staff (if applicable), I maintain a zero-tolerance weapons policy. No weapon of any kind is permitted on the premises, including guns, explosives, ammunition, knives, swords, razor blades, pepper spray, garrotes, or anything that could be harmful to yourself or others. I reserve the right to contact law enforcement officials and/or terminate treatment with any client who violates my weapons policy.
Telemental Health
Telemental Health is defined as follows:
“Telemental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. Telemental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.” (Georgia Code 135-11-.01)
Telemental Health is a relatively new concept despite the fact that many therapists have been using technology-assisted media for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of Telemental Health services in order to provide you with the highest level of care. I have also developed several policies and protective measures to ensure your PHI remains confidential. These are discussed below.
The Different Forms of Technology-Assisted Media Explained
Telephone Via Landline: It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and you provided me with that phone number, I may contact you on this line from my own cell phone, typically only regarding setting up an appointment if needed. If this is not an acceptable way to contact you, please let me know. Telephone conversations (other than just setting up appointments) are billed at my hourly rate.
Cell Phones: In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you, typically only regarding setting up an appointment if needed. Telephone conversations (other than just setting up appointments) are billed at my hourly rate. Additionally, I keep your phone number in my cell phone, but it is listed by your initials only and my phone is password protected. If this is a problem, please let me know, and we will discuss our options.
Text Messaging: Text messaging is not a secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to text because it is a quick way to convey information. Nonetheless, please know that it is my policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via text to prevent compromising your confidentiality. You also need to know that I am required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy.
Email: Email is not a secure means of communication and may compromise your confidentiality. However, I realize that many people prefer email because it is a quick way to convey information. Nonetheless, please know that it is my policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that I am required to keep a copy or summary of all emails as part of your clinical record that addresses anything related to therapy.
I also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password protected, does not access the internet through a public wireless network, etc.). If you are in a crisis, please do not communicate this to me via email because I may not see it in a timely matter. Instead, please see below under "Emergency Procedures."
Your Responsibilities for Confidentiality & Telemental Health
Please communicate only through devices that you know are secure, as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any Telemental Health sessions.
In Case of Technology Failure: If we are on a phone session and we get disconnected, please call me back or contact me to schedule another session. If the issue is due to my phone service and we are not able to reconnect, I will not charge you for that session.
Limitations of Telemental Health Therapy Services: Telemental health services may have some limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if on a phone call, I will not see a tear in your eye. Or, if audio quality is lacking, I might not hear the crack in your voice that I could easily pick up if you were in my office.
There may also be a disruption to the service (e.g., the phone gets cut off or the video drops). This can be frustrating and interrupt the normal flow of personal interaction.
Please know that I have the utmost respect and positive regard for you and your well-being. I would never do or say anything intentionally to hurt you in any way, and I strongly encourage you to let me know if something I've done or said has upset you. I invite you to keep our communication open at all times to reduce any possible harm.
Consent to Telemental Health Services: Using the form at the bottom of this page, please check the Telemental Health services you are NOT authorizing me to utilize for your treatment or administrative purposes. Together, we will ultimately determine which modes of communication are best for you. However, you may change your mind and authorize the use of any of these services at any time during the course of your treatment just by notifying me in writing. If you do not see an item discussed previously in this document listed for you to opt out of, this is because it is a standard feature built-in to the majority of therapy practices, and I will be utilizing that technology unless otherwise negotiated by you (e.g., an encrypted electronic health records platform that includes a portal for communication and scheduling). Again, please Opt-Out of any of the following technology you would NOT like for me to utilize in your treatment.
In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Feel free to ask questions, and please know that I am open to any feelings or thoughts you have about these and other modalities of communication and treatment.
Communication Response Time
My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful. I do not carry an emergency phone, nor am I available at all times. If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. I will return phone calls, text, and emails within 36 hours. However, I may not return calls or any form of communication on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.
In Case of an Emergency
If you have a mental health emergency, I encourage you not to wait for communication back from me but do one or more of the following:
Call Behavioral Health Link/GCAL: 800-715-4225
Call Emory University Hospital at Wesley Woods (Atlanta): 404-728-6222
Ridgeview Institute (Smyrna): 770-434-4567
Peachford Hospital (Atlanta/Dunwoody): 770-454-5589
Athens Behavioral Medicine (Athens): 706-850-8558
Advantage Behavioral Health Systems (Athens & Watkinsville): 855-333-9544
Laurel Heights Hospital (Atlanta): 404-888-5475
Skyland Trail (Atlanta): 866-504-4966
Call the local mental health hospital that you list in the following section.
Call or text 988 Suicide Prevention & Crisis Line
Crisis Text Line: Text “Home” to 741741
Call 911
Go to the emergency room of your choice
If we decide to include Telemental Health as part of your treatment, there are additional procedures that we need to have in place specific to Telemental Health services. These are for your safety in case of an emergency and are as follows:
You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telemental Health services are not appropriate.
I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-threatening emergency only. Please write this person's name and contact information below. Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency. Additionally, if either you, your ECP, or we determine it is necessary, the ECP agrees to take you to a hospital. Your signature at the end of this document indicates that you understand we will only contact this individual in the extreme circumstances stated above. Please list your ECP using the form at the bottom of this page.
You agree to inform me of the address where you are at the beginning of every Telemental Health session.
You agree to inform me of the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health emergency (usually located where you will typically be during a Telemental Health session). Please list this hospital and contact number using the form at the bottom of this page.
Structure and Cost of Sessions
Based on your treatment needs, I may provide services face-to-face, or by phone, text, or email. The structure and cost of both in-person sessions and Telemental Health are $200 per 60-minute session and $300 per 90-minute therapy session. The fee for each session will be due at the conclusion of the session. Cash, personal checks, Square, Venmo or Paypal are acceptable for payment, and I will provide you with a detailed receipt of payment. I do not accept insurance; however, I can provide a detailed receipt, which you may be able to submit for reimbursement through your Health Savings Account (HSA) or out-of-network insurance benefits, depending on your plan. Please note that there is a $35 fee for any returned checks.
Phone calls, texting, and emails (other than just setting up appointments) are billed at my hourly rate for the time I spend reading and responding. Again, this includes any therapeutic interaction other than setting up appointments.
Cancellation Policy
If you are unable to keep an appointment, you must notify me at least 24 hours in advance. If such advance notice is not received, you will be financially responsible for the session you missed. Please note that your signature below indicates that you understand if you dispute a cancellation charge on your credit card, I will need to provide this document to your credit card company as proof that you agreed to this policy. This would mean that your credit card company would see that you agreed to be treated in my practice. I would not disclose any PHI other than this Informed Consent agreeing to my policies.
Our Agreement to Enter into a Therapeutic Relationship
Please complete the form below indicating that you have read and understand the contents of this “Information, Authorization, and Consent to Treatment” form, as well as the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices” provided to you separately. Your electronic signature also indicates that you agree to the policies of your relationship with me and that you authorize me to begin treatment with you. I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any questions about any part of this document, please ask.