Welcome to your Counseling Clinic. Please take a few minutes to read through this informed consent form to understand more about counseling and get to learn more about the solutions that can address your concerns to get you back on track.
COUNSELING. Counseling is a process carried on in a one-on-one social engagement between a professional psychologist or psychiatrist, known as counselor or therapist, acting to help a client seeking to learn more about himself or herself, exploring difficulties, and to understand the society that surrounds himself or herself in reaching defined positive goals for a better chance to become a productive member of society.
CONFIDENTIALITY. We highly respect the privacy and confidentiality of each of our clients. We likewise believe that for counseling to be effective and successful, we must make our clients feel secure about the information that they disclose with us. We keep our clients' records in a secure manner and we do not allow it to be accessed or to be shared with anyone else unless with the written consent of our client who owns the information, both clinical information and personal. If records receive no update within a period of 7 years, we purge the records for privacy protection.
However, we would like to let you know that privacy has its limitations in law and we would like to inform you of the circumstances where we may share information to a 3rd party without your consent:
SESSION APPOINTMENTS. Each session takes 1 hour. Counseling sessions are on the reservation and by appointment. In case the client will not be able to attend the scheduled appointment, he/she should call 24-hours prior appointment or he/she will be charged 100% of the session fee.
FEES. Fees are charged on a per session basis. We may directly bill your insurance company by informing us of the details. If you planning to pay, here are our schedule of fees:
• 1-hour Session ($100)• Marriage Counseling ($100)• Family Counseling ($150)• Meditation (45 mins): $175• Court Witness (expert witness) ($200)
RELATIONSHIP. The relationship required for effective counseling is strictly professional. This is for the best interest of the parties. The therapist cannot have any other relationship with the client than a professional one.
I understand that this consent is purely voluntary. I have had the opportunity to discuss any concerns with regard to the services and treatment and by which all questions were answered accordingly and to my satisfaction.
I understand that I can withdraw anytime from the therapy by informing my therapist. By signing below, I expressly give my consent to the treatment and therapy sessions with the therapist.