Welcome and thank you for choosing Mending Clinic for your counseling services. Today’s appointment will take approximately 180 minutes after you have completed the forms. We realize that beginning a process of counseling may be a major decision that you have made and may have many questions. This document is intended to inform you of our policies, state and federal laws, and your rights. If you have any questions or concerns, please ask and we will try our best to give you all the information you need. When you sign this document, it will represent an agreement between you and Mending Clinic.

Our Counseling Center

We are dedicated to providing the highest quality in our areas of respective expertise to our community. Our mission is promoting a positive emotional and psychological lifestyle for our clients through counseling and psychotherapy services. At Mending Clinic, we also offer bilingual (Spanish) counseling.

Our Therapists

Our therapists are graduates from a major accredited University, holding a Master’s degree in Counseling. Each therapist is a Licensed Professional Counselor or Licensed Professional Counselor- Intern through the Texas State Board of Professional Counselors. Our interns are in the process of completing the required 3,000 intern hours; they are under supervision to ensure that you will receive the highest excellence of service. Also, we have therapists that are Licensed Marriage and Family Therapists or Licensed Marriage and Family Therapist-Associates. The Licensed Marriage and Family Therapist- Associates are supervised by the State Board of Examiners of Marriage and Family Therapist approved Supervisors. Mending Clinic carefully selected the interns or associates based on their knowledge, character, ethics, experience, and passion to help. If you have any questions regarding any intern or associate, ask to speak with the Clinical Director of Mending Clinic, Jorge Gama LPC-S.

If you have any complaints with a LPC or LPC-Intern, you may contact:

Texas Board of Examiners of Professional Counselors Texas Department of State Health Services
MC-1982
1100 West 49th Street, Austin, Texas 78756-3183
E-mail: lpc@dshs.state.tx.us
Website: http://www.dshs.state.tx.us/counselor
Telephone: (512) 834-6658
Fax: (512) 834-6677

If you have any complaints of a LMFT or LMFT-A, you may contact:

Texas Board of Examiners of Marriage and Family Therapists
Texas Department of State Health Services
MC-1982
P.O. Box 149347, Austin, Texas 78714-9347
E-mail: mft@dshs.state.tx.us
Website: http://www.dshs.state.tx.us/mft
Telephone: (512) 834-6657
Fax: (512) 834-6677

Psychological Services

Psychotherapy is not easily described in general statements. It varies depending on the personality of the psychotherapist and the client and the particular problems you bring forward. There are many different methods your therapist may use to deal with the problems that you hope to resolve. Psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Moreover, psychotherapy has also shown to have great benefits for people who go through the process. Therapy often leads to an improved relationship, solutions to specific problems, and significant reductions in feelings of distress. However, there are no guarantees of what you will experience.

Our first session will involve a 180 minute evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with Mending Clinic. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

Sessions

Your therapist and you will meet today for approximately a 180 minute session for a behavioral health assessment to evaluate current levels of cognitive functioning to assist with treatment planning for psychotherapeutic treatment. During this session please provide your therapist with information that is as current, complete and as truthful as possible. Adjusting any notes, reports or assessments after the session with information that is not current, complete or true will be considered fraud and is not possible according to the Texas Board of Examiners of Professional Counselors.

Electronic Communication

The therapist at Mending Clinic will make efforts to respond to your email promptly but cannot guarantee that any particular email message or text message will be read and responded to within any certain time frame. Because the response cannot be guaranteed please do not use email or text messaging in a medical emergency. Should you choose to communicate by email or text messaging, please understand this is for appointment changes/clarification and sharing information. Therapy will not be conducted through email or text message. Any pertinent correspondence will be printed and made part of your medical record.

HITECH and HIPAA

Please be aware that electronic devices run the possibility of a “breach of confidentiality” with protected information. A “breach” is defined in the new 2013 rules as the improper “acquisition, access, use or disclosure of protected health information in a manner not permitted under subpart E of this part which compromises the security of privacy of the protected health information.

By signing I am agreeing that I understand my choice and risk in the box I have checked.

Court Fee Agreement

In the event of a court action in which a Mending Clinic contracted therapist is requested or required to participate, I accept full financial responsibility for the following fees:

Depositions, court testimony, record review and attorney conference calls:

• $500 an hour with a four-hour minimum charge

Copying of records and associated administrative costs:

• $20.00 per hour for labor and costs of supplies for chart copying
• $25.00 for the first twenty pages of copying
• $0.50 per page thereafter

When any court action is required, a retainer in the range of $2,000-$5,000 is required to be paid five business days prior to the court date. All Subpoenas are expected to be in the proper form and delivered by a process server to our office. Up to five business days are required for Mending Clinic to provide client records.

I agree that the party whose attorney issues any subpoena for depositions or court appearances will be the responsible party paying the retainer fee unless otherwise specified. By signing this document I understand this to be a binding contract.

Confidentiality and Limitations

All communication with your counselor, psychologist, or psychiatrist is confidential and will not, except under circumstances explained below, be disclosed to anyone outside of Mending Clinic unless you give written authorization to release information. You will need to sign a Release of Information Form if you wish to have Mending Clinic professional staff communicate information to anyone. Under the HIPAA Omnibus Rule is that, at the client’s request, counselors may not disclose treatment information to the client’s health insurance carrier for which the client has paid out-of-pocket, unless the disclosure is required by law.

A record is kept of your work with us. It contains information you have provided us in writing as well as counseling notes of your sessions. The record remains in Mending Clinic for a period of seven years following your last visit; at that time, it is destroyed. Your record never leaves Mending Clinic.

It is important that you understand that all identifying information about your therapeutic treatment is kept confidential. Information solicited by phone, written, or in person about clients will not be provided. You will need to sign consent to release information before any information is provided to a third party outside our office. This condition applies also in cases where coordination of treatment is necessary with another health professional (physician or psychiatrist However, there are exceptions and/or limitations to confidentiality. The following are limitations to confidentiality:

• In cases of immediate risk/threat of suicide or homicide on the part of the client
• In cases of child or elderly sexual abuse or neglect
• In cases required by law.

Emergency Situations

In the event of an emergency, contact your family physician or the nearest emergency room and ask for the clinician/psychologist/psychiatrist on call.

Professional Fees & Fee Agreement

Our Fee Schedule is as follows:

• Diagnostic & Behavioral Health Assessment - $500.00
• Traditional processing is approximately six weeks. If assessment is needed within fourteen days there will be a $100.00 expedite fee
• If inaccurate information is provided by the client there will a $50.00 correction fee due before corrections are made.
• One report is included with the assessment for the attorney, more reports are available at the cost of $25.00 per copy.
• Follow up sessions are available if necessary and they are $100.00 per session (30-60 minutes).

Consent to Treatment

By signing this Client Information and Consent Form as the client or Guardian of said client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receiving a behavioral health assessment to assess treatment levels and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time. I also understand that any therapist that is providing counseling services is at a contract status with Mending Clinic.