Confidentiality Agreement

Welcome to Restored Faith Counseling and Consulting.

 

This document contains our office policies. If you have any questions, your counselor will gladly discuss them with you. 

 

Confidentiality

The Law protects the privacy of communication between a client and a therapist.  In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. Your signature on this Agreement provides consent to the following: 

 

  • I may occasionally find it helpful to consult other health and mental health professionals about a case.  During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential.

 

  •  As a Registered Mental Health Counselor Intern, I am under the supervision of a qualified supervisor, Joy Berkheimer, LMFT. Joy is a licensed mental health counselor and has taken the proper courses to train new counselors. In some cases, I consult with her and receive guidance. During these conversations, however, I do not disclose identifying information. She is also bound by the same rules of confidentiality.  

  • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

 

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a client’s treatment.  These situations are unusual.

  • If I have reason to believe that child has been abused, the law required that I file a report with the Department of Children and Families (DCF). Once such a report is filed, I may be required to provide additional information. 

  • If I have reasonable cause to believe that a disabled adult or elder person has been abused, I am required to report that to the appropriate agency. Once such a report is filed, I may be required to provide additional information. 

  • If I determine that a client presents a serious danger of violence to another, I may be required to take protective actions.  These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client.  If such a situation arises, I will make every effort to fully discuss it with you before taking any action, and I will limit my disclosure to what is necessary. Please feel free to discuss any concerns or questions you may have about confidentiality.

 

Professional Records Restored Faith Counseling keeps a set of professional records, which provide pertinent information regarding the contents of the session. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in the presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents.  In most situations, we charge a copying fee (fee varies by case) for sending these records. 

 

Appointments Each therapy appointment is traditionally a 60‐minute session unless specially arranged by the therapist. Once an appointment is scheduled, it is your responsibility to keep track of the dates and times of your appointments.  If you must cancel your appointment or need to reschedule, please phone the office at least 24 hours in advance of your scheduled appointment.

A late cancellation fee will be billed to you for the time that was reserved for your appointment. This fee is typically 100% of the fee for the scheduled appointment. We reserve the right to terminate treatment with a client for failure to show up at two or more appointments.  In cases of emergencies and/or hospitalizations, please discuss concerns with your therapist, as reducing/waiving this fee is at the discretion of the individual therapist. 

 

Professional Fees The hourly fees for services vary.  Please speak to your individual therapist for details. We ask that your account be kept current and payments be made at the conclusion of each session. We accept cash, check, Visa or MasterCard. If your check is returned, you will be responsible to pay the original amount due plus a $15 processing fee.  Should the fee not be paid for two or more sessions, no further sessions will be scheduled until the balance is paid and/or payment arrangements have been made with your counselor. At the conclusion of treatment, all outstanding fees must be paid upon termination. 

 

Telephone Calls Please know that every call is important to us and we do our best to answer each call.  If we are not able to answer your call immediately, please leave a voicemail with your name, number, and the nature of the call, and we will return your call within the next business day. In the event of a crisis, please dial 911 or the National Suicide Prevention Lifeline: 1-800-273-8255.

 

Consent Your signature below indicates that you have read this agreement and consent to treatment by our providers under these terms and conditions.  This agreement also serves as an acknowledgment that you understand the HIPAA privacy guidelines.  If you would like a copy of this agreement, we will be glad to copy the signed form for you.  

 

Signature:  ____________________________________________________________

Date: _______________________________________________________________