Center For Individual & Family Therapy A Christian Counseling Center Family Forms printable pdf download

CONSENT TO CONSULTATION/TREATMENT

Welcome to the Center for Individual & Family Therapy a Christian counseling center. The following is an

agreement to enter into a CONSULTATION/TREATMENT PROCESS. During the consultation process both you

and your therapist may mutually agree to decide to move into psychotherapy treatment together.

CONSULTATION PROCESS: First sessions are a consultation, which usually include: Completing necessary

paperwork, meeting with a therapist and taking a Personality Assessment Inventory (PAI) with an additional

$20 fee.

Please be aware that after the first consultation it is sometimes necessary to refer you to another CIFT

clinician that can better meet your needs. If this occurs, your file will automatically be transferred to that

CIFT clinician. If for some reason we are not able to help you at CIFT, your file can be transferred to an

outside therapist with your written permission.

APPOINTMENTS: It is your responsibility to notify your therapist at least 48 hours in advance if you are

unable to attend your appointment. Cancellations of appointments less than 48 hours in advance and

“no shows” are subject to the full fee for the appointment time.

Your therapist may offer communication through email or texting for the purpose of scheduling only. Emails

to your therapist may not include therapeutic content or information regarding danger to one self or others.

Your therapist is not available 24 hours a day, in case of emergency, please call 911 or go to the nearest

emergency room.

PAYMENT & FEES: You are expected to pay for services at the time they are rendered unless

other arrangements have been made. Services are rendered and charged to the client, not to the

insurance company. Your therapist will provide you with a receipt to submit to your insurance company for

reimbursement. You may also incur charges for phone calls lasting more than 15 minutes, letters and

testing fees. Your fee may be subject to an annual increase. There is a $20.00 charge for returned checks.

Fees for writing expert testimony for court purposes will be charged at a higher rate than session fees.

I, the client, agree to be responsible for the payment of $________per session (45 minutes)

which is payable at the time of the session. I understand that I am responsible for payment, even

though I may be reimbursed by my insurance company.

Client Initials _________

LIMITS ON CONFIDENTIALITY: In certain situations a therapist is mandated or permitted by law to take

actions that he/she believes are necessary to attempt to protect client or others from harm, and he/she may

be required to reveal limited information about a client’s treatment. Those situations can include: child

abuse, danger to self, threat of violence to others, and elder/dependent adult abuse.

PRIVACY: The law protects the privacy of all communications between a client and a therapist. In most

situations, your therapist can only release information about your treatment if you sign a written

Authorization Form that meets state law requirements. However, your therapist is permitted or

required to disclose information without either your consent or authorization under the following

conditions:

•

CONSULTATION: Your therapist may seek advice from professionals. During a consultation, he or she

will make every effort to avoid revealing the identity of clients. The other professionals are also legally

bound to keep the information confidential. Your therapist may not discuss these consultations with you.

All consultations are noted in your Clinical Record.

•

CONTRIBUTION TO KNOWLEDGE: Our therapists may write books, teach and/or lecture at various

venues. We are also a training site for pre-licensed therapists. On occasion CIFT therapists may use

disguised case data for writing, teaching or training purposes only. No identifying information is included.

•

ADMINISTRATIVE STAFF: Your therapist may need to share protected information with administrative

staff for both clinical and administrative purposes, such as scheduling, billing, and quality assurance.

Staff members have been given training about protecting your privacy and know not to release any

information outside of the practice without the direction from a professional staff member.

•

COLLECTION: If you do not pay your fee, we are legally permitted to contact a collection agency.

•

GOVERNMENT AGENCIES: If a government agency is requesting the information for health oversight

activities pursuant to their legal authority, your therapist may be required to provide it for them.

•

LAWSUITS: If a client files a complaint or lawsuit against his/her therapist, relevant information may be

disclosed regarding that client without client consent in order for the therapist to defend himself/herself.

Center For Individual & Family Therapy A Christian Counseling Center Family Forms

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