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Informed Consent for Counseling Services

This form provides you, the client information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.

CONFIDENTIALITY : All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to Shelly D Sanders LCSW that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Shelly D Sanders LCSW. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Shelly D Sanders LCSW will use her clinical judgment when revealing such information. Shelly D Sanders LCSW will not release records to any outside party unless she is authorized to do so by all adult parties who were part of the family therapy, couple therapy, Parent coaching or other treatment that involved more than one adult client.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Shelly D Sanders LCSW becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided on the biographical sheet.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Shelly D Sanders LCSW, only the minimum necessary information will be communicated to the carrier. Shelly D Sanders LCSW has no control over, or knowledge of, what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Shelly D Sanders LCSW to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

CONSULTATION: Shelly D Sanders LCSW consults regularly with other professionals regarding her clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted e-mail, texts, and e-faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e-faxes that go through them. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Shelly Sanders LCSW LLC computer is equipped with a firewall, a virus protection and a password, and she backs up all confidential information from her computer on a regular basis onto an encrypted hard-drive. Please notify Shelly D Sanders LCSW if you decide to avoid or limit, in any way, the use of e-mail, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts or e-fax or via phone messages, will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and she will honor your desire to communicate on such matters. Please do not use texts, e-mail, voice mail, or faxes for emergencies.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Shelly D Sanders LCSW between sessions, please leave a message if she is unavailable and your call will be returned as soon as possible. Shelly D Sanders LCSW checks her messages a couple times during the daytime only, unless she is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call Psychiatric Emergency Services. Kootenai Health Emergency Room (208) 666-3000, go to your nearest emergency room or the Police: 911. Please do not use emails or texting for emergencies. Shelly D Sanders LCSW does not always check her email daily, and does not typically utilize text messaging as a form of communication with her clients.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy, can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part and risks in your mental health treatment. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Shelly D Sanders LCSW will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Shelly D Sanders LCSW may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy to include parent education and coaching will yield positive or intended results. During the course of therapy, Shelly D Sanders LCSW is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), positive psychology, solution focused, mindfulness training, attachment and trauma, or psycho-educational. Shelly D Sanders LCSW provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Shelly D Sanders LCSW will discuss with you her working understanding of the problem, treatment plan, therapeutic objectives, and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Shelly D Sanders LCSW expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

GROUP THERAPY: In group therapy, it is of utmost important that all members maintain confidentiality and neither disclose the content of sessions nor the identity of fellow group members. It is highly recommended that any meaningful exchange outside the group also be discussed in the group. In group therapy, the other members of the group are not therapists. They are not regulated by the same ethics and laws that bind your therapist. The limits of confidentiality and the reporting laws have been outlined earlier in this document. While the expectation is that all group members will maintain confidentiality regarding anything said in the group, you cannot be certain that they will. You are ultimately responsible for what you say and what you think, feel, or do with the feedback you receive in the group.

TERMINATION: As set forth above, after the first couple of meetings, your therapist will assess if she can be of benefit to you. Shelly D Sanders LCSW does not work with clients who, in her opinion, she cannot help. In such a case, if appropriate, she will give you referrals that you can contact. If at any point during psychotherapy and or parent coaching, attachment education, Shelly D Sanders LCSW either assesses that he is not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, she will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, she would give you a couple of referrals that may be of help to you. If you request it and authorize it in writing, Shelly D Sanders LCSW will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Shelly D Sanders LCSW will give you a couple of referrals that you may want to contact, and if he has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, your therapist will provide you with names of other qualified professionals whose services you might prefer.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours’ notice is required for re-scheduling or canceling an appointment. This allows us to provide access to treatment for clients on the waiting list and clients in crisis. Unless we reach a different agreement, a fee of $65.00 will be charged for sessions missed without such notification. Insurance companies do not reimburse for missed or late sessions. More than 2 cancellations without notification could result in termination of services or a referral to a different provider. To help avoid charges for missed sessions we offer appointment reminders 24 hours in advanced for your session. (phone call, email, or text message if needed)

PATIENT RIGHTS: Right to impartial care, considerate, respectful care, personal and informational privacy, to know the identity and professional status of your counselor, obtain complete and current information on your diagnosis, informed participation in decisions involving your care, know the reasons for any transfer or referral of care, request and receive an itemized bill, consultation of another professional at your own expense, refuse treatment to the extent permitted by law, request a copy of your treatment record at .10 per copy, to express written grievances, voice complaints or to appeal a decision related to your treatment and receive a response within two business days.

PATIENT RESPONSIBILITIES: Failure to comply with the following may result in termination of services. Provision of information, you have the right to provide, to the best of your knowledge, complete information about present complaints, past illnesses, to report unexpected changes to your condition to your counselor. You are responsible for making it known whether you understand your course of treatment and what is expected of you, refrain from the use of illegal substances, refrain from threatening staff, inform the counseling agency immediately to any changes made in your insurance benefits and if you fail to follow reasonable treatment recommendations we reserve the right to refer you to another provider within 30 days notice, provide prompt payment for services rendered, let this counseling agency know if you loose insurance benefits, provide 24 hour notice cancellations.

CONSENT TO TREAT MINORS
If you are under eighteen years of age, please be aware that the law may give your parents or guardians the right to obtain information about your treatment and/or examine your treatment records. It is my policy to request a written agreement from your parents or guardians indicating that they consent to give up access to such information and/or, to your records. If they agree, I will provide them only with general information about our work together subject to your approval, or, if I feel it is important for them to know in order to make sure that you and people around you are safe. If I think it is appropriate, I will involve them if I feel that there is a high risk that you will seriously harm yourself or another/others. Before giving them any verbal or written information, I will discuss the matter with you, if possible. I will do the best I can to resolve any differences that you and I may have about what I am prepared to discuss.

I have read the above Counseling Services and Informed Consent for Psychotherapy carefully, understand my rights and responsibilities as a patient, risks and benefits of treatment, cancellation policy and the mental health professional's duty to warn, consent to treat minors. I understand them and agree to comply with them.

,have agreed to voluntarily enter into treatment , or give my consent for the minor person or person under my legal guardianship mentioned above Shelly D Sanders LCSW, LLC.

Signature

PROFESSIONAL FEES, PAYMENTS & INSURANCE REIMBURSEMENT: I am aware that I am responsible for any co-payments or private fees for services at time of my appointment unless other arrangements have been prior authorized by Shelly D Sanders LCSW. I also acknowledge that if there are any costs not paid by my insurance company, I am responsible for these as well. By signing below I am taking responsibility for any co-payments or private fee services that incur with Shelly D Sanders LCSW, LLC.

Call For An Appointment Or Email Us

Informed Consent for Counseling Services

Informed Consent for Counseling Services

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2454 West Grenoble Lane Coeur d Alene Idaho 83815

(208) 964 - 2113

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