Informed Consent for Walk the Walk Counseling LCC

I am licensed as a Clinical Social Worker in the state of New Mexico. I have a Master’s Degree in Social Work and a credential in School Counseling, and a Bachelor’s Degree as a Recreational Therapist. I am also a trained facilitator of Love and Logic. It is important that you understand you are entering into a counseling relationship with me.
If we discover that another source of therapy may benefit you, I will discuss this with you and refer you to what may be most helpful. I prefer to primarily address counseling from a person-centered, humanistic, holistic, cognitive behavioral model. Holistic meaning addressing the whole life of the person, not just the problem they are seeking counseling for. The cognitive-behavioral model focuses on the primary concern that you have right now. Once this problem or concern is identified, you and I will work together to set treatment goals that result in solving the problem or concern.

The goal of counseling is to reduce internal distress and problems in one’s life. Some individuals may experience an exacerbation of problems or different problems in the course of counseling. These problems can increase anxiety, depression, sadness, sleep disturbance, intrusive thoughts, flashbacks, self-destructive or angry impulses, suicidal tendencies and problems in family relationships. In some situations, hospital care may be necessary.
Persons who are in counseling/therapy benefit from having a support system. Expressive activities such as exercise, art, writing, and music are helpful in one’s healing. Other treatment modalities such as family therapy, group counseling, 12 step groups and support groups, medication, natural and alternative healing modalities may be helpful. Referrals can be provided to help develop a support system at your request.

Medical Concerns

I cannot recognize or diagnose medical conditions. It is recommended that you obtain a medical examination to determine any medical origins for your psychological problems, neurological disorders, endocrinological disorders, side effects of medication etc. Not being a medical doctor, I cannot prescribe medication but will refer you for psychiatric consultation if this appears to be indicated.

Assessment

I must conduct both an initial and ongoing assessment to understand your psychological needs. It is essential that you cooperate by completing all forms requested. Please be completely open and honest about your symptoms. I can only help you with your problems to the extent of the information you provide.

Confidential Therapy

The content of your sessions will be held confidential. I cannot release any information or confirm or deny that you are in counseling without your written consent.

Confidentiality from Third Parties

Counseling and therapy are confidential from parties with important exceptions:

  1. Information may be released to designated parties by written authorization of clients or legal guardians.
  2. When you seek reimbursement for therapy/counseling from insurance companies or other third parties, information, including psychological diagnosis, and in many cases, explanations of symptoms and treatment plans, and in rare cases, entire client records, must be provided to the third party. If health coverage is provided, employers could possibly have access to such information. They are required by law to adhere to HIPPAA regulations of confidentiality.
  3. I am required to release information obtained from collateral sources, other individuals involved in your counseling/therapy to which such disclosure may help to avert danger to any psychotherapy client or others. This can include imminent risk of suicide, homicide, abuse of a child or a disabled or elderly person, and destruction of property that could endanger others. I am required to report when you are at imminent risk of a life-threatening danger. This includes suicidal or homicidal intent or action, suspected past or present abuse or neglect of children, adults and elders, and children being exposed to domestic violence. I am required to report to the authorities including CYFD and law enforcement based on information provided by you and/or collateral sources.

If you are required to undergo counseling as a result of a court order or mandate from DHS, a private institution, or probation departments, I may be required to provide all notes of your therapy and contact with collateral sources in response to a court order or legitimate subpoena. I do not provide any recommendations for child custody, settlement cases or other legal issues.

As a Therapist and professional educator, I often consult with other professionals on cases and teach about the psychotherapy process. I disguise identifying information when doing so. Please indicate if you wish to place restrictions on consultation or teaching related to your case.

Cell phone, texts, faxes, written letters and email communications can be intercepted by third parties. I cannot guarantee complete confidentiality when communicating with you or your insurance companies via these forms of communication. We can discuss how you want to communicate. I am required to make a record of each client contact. Emails are included as part of your file.

 

Professional Records

The New Mexico Board of Social Work requires that I keep treatment records. I am required to keep your records for 7 years. At the completion of 7 years, I have your records destroyed via a confidential recycling facility. Your documents are shredded. I am present and witness this event Additionally, I keep an electronic file. Professional records can be misinterpreted and/or upsetting to untrained readers. You are entitled to receive a copy of your records. I charge copying costs of $2.00 per sheet for professional time spent responding to information requests. Your records will be provided within 30 days of your documented request. Your record includes a copy of the signed informed consent form, acknowledgment of receipt of privacy policies and practice, treatment notes, and any release of protected health information and copies of your bill or insurance submissions. Paper records are scanned and stored electronically.

 

Alternative Treatments

Other treatment approaches are sometimes used when I counsel or provide therapy. I will also discuss these approaches beforehand with you and ask for your consent to proceed. Such techniques may include, breath work, teaching meditation techniques, expressive journaling or art therapy, group counseling, mindfulness techniques referrals to 12-step groups, and referrals to a variety of practitioners based on you request or interest. I will explain each of these methods and receive your permission prior to implementing them.

 

Fees

Counseling and therapy sessions and collateral contacts are $125.00 per 50 minute session. This includes any time missed by being late or a missed appointment. I am paneled with PHS, NMHC, and Molina HC at this time.  I accept most credit and debit cards, cash, checks, and cashier’s checks. I am willing to enter into payment plans without interest as long as the payments are made on time. I will consider sliding my fees from $65.00-$125.00 per session. The fee schedule is a case by case situation. Insurance benefits are never a guarantee of payment. I reserve the right to release financial information to a collection agency, attorney or small claims court if you are delinquent in paying your bill.

 

Length of Counseling or Therapy

Some problems can be alleviated in just a few sessions. Other problems require longer treatment. It is often difficult to predict the length of therapy needed. The decision to terminate therapy belongs to you or at the therapist’s recommendation. If termination occurs before adequate treatment has been achieved, I will provide you with referrals to other providers upon your request or you may choose to find your own therapist.

 

Cancellations

Please understand that your appointment is reserved for you. I cannot provide this service to someone in your place if you do not give me enough notice to do so. You agree to call 24 hours in advance if you must cancel a session. If less than 24 hours notice is provided, you will be billed the regular session fee of $125.00, unless a sudden medical emergency has occurred. Two late cancels or no-shows within a 2-month period will result in termination of counseling and a referral to another provider, or suspended until the matter that prevents attendance is resolved. Insurance will not pay for missed appointments.

 

Emergencies

I am on call, and my current office hours are Friday evening and Saturday morning I am not always immediately available by phone. It is imperative that you always leave a message on my voicemail with the best number to reach you.  Please call (505) 639-1312. If it is a life or death situation or you or another person is in a severe mental health crisis, CALL 911 or go to the nearest hospital emergency room.  If you need to speak with someone right away, you can call Agora Crisis 277-3013 or 855-505-4505. You can also connect with them online at anytime: http://www.agoracares.org/. Also, you can contact the New Mexico Crisis line http://www.nmcrisisline.com/. Their number is 1-855-662-7474.

 

Social Media, Email, Texting

I do allow clients to contact me through email at walkthewalkcounseling@gmail.com. It is not, however, a forum for discussing very serious issues or counseling. Therefore, you can expect brief responses from me until we can talk on the phone or at your next session. I do allow you to text me, however, I will not use texting as a means to discuss counseling issues. Texting should be reserved for appointment issues or minimal communication. You will need to identify on your intake form if I can contact you by email or texting and accept and understand the confidentiality limitations in doing so. I do not add any clients to Facebook, etc.

 

Contact Outside of the Office

As your therapist, I am obligated to do my best at keeping our relationship professional and confidential. Therefore, I will not accept invitations to weddings, birthdays, etc. Additionally, if we run into each other in the community, I typically will not acknowledge you because of confidentiality reasons. I do not accept gifts from clients as I do not want you to feel obligated in anyway. I appreciate the kindness and thoughtfulness, however, a verbal or written “thank you” is more than enough and means a great deal to me.

 

Termination of Counseling

You may terminate counseling at anytime. Primarily, termination of therapy is usually a collaborative agreement. As your therapist, I may choose to terminate counseling with you as a result of lack of attendance, or if I have reason to believe you should be referred to another professional, if I am finding that your needs are out of my scope of service or for other ethical reasons set forth by my licensing board. I will provide you with a list of 3 names or agencies you may contact to transfer care or you may contact your insurance company or find other providers of your own choosing. If you are absent from counseling for over 30 days and wish to return, it may require a new intake assessment.

 

I will provide a form to you titled ‘Consent for Treatment’. Signing the form provides an acknowledgment that you have reviewed this Informed Consent statement and agree to the terms. This will also be noted on that form. You are welcome to print this for your records or ask me for a copy of your files.