Informed Consent for Counseling, Confidentiality Policies, and Financial Agreement

Mental Health Services

RecPlay Counseling Center is committed to assist you to grow toward improved health by providing counseling services within cognitive-behavioral therapy, recreational play therapy, and family therapy. Our clinician works within the context of each individual client’s beliefs and no attempt is made to impose any personal theology.

Goals, Purpose, and Techniques of Counseling and Psychotherapy

There may be multiple interventions to effectively treat difficulties reported and observed throughout the course of treatment. It is important for you to discuss any questions you may have regarding treatment recommended by your clinician and to have input in setting goals in treatment. As treatment continues, these goals may change.

Confidentiality

Discussions between clinician and client are confidential. No information will be released without client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of clients in mental health facilities; situations where the therapist has a duty to disclose, or where, in the therapist’s judgement, it is necessary to warn, notify, or disclose; fee disputes between the clinician and the client; a negligence suit brought by the client against the clinician; or filing of a complaint with a licensing board or other state or federal regulatory.

Regarding confidentiality and parents of minor children, Georgia and national laws protect both the parent’s right for their child’s mental health records and that same child’s rights to the same protection of confidentiality as an adult’s mental health records. For the purpose of practicality regarding these opposing protections, it is RecPlay Counseling Center policy that outside of ‘duty to warn’ reports made in session, the clinician will only upon request provide a full detail report of interventions conducted in treatment but brief and very limited report – if any at all – of the child’s responses of those same aforementioned interventions. Recplay Counseling Center policy regarding confidentiality in matters of separation, divorce, and potential initiation of a blended family has just as much purpose in obtaining and maintaining a safe, secure environment for a minor, therefore it is agreed that every protection will be made – outside of extreme circumstances – that reports made in treatment by child remains confidential. This confidentiality includes, but is not limited to, divorce court cases, custody disputes, and any other parental/custodial conflict civil or otherwise.

If you have any questions regarding confidentiality, you should bring them to the attention of the clinician when you and the clinician discuss this matter further. By signing the form of the informed consent and Privacy Practices, you are giving consent to the clinician to share confidential information with all persons mandated by the law. You are also releasing and holding harmless the clinician from any departure from your right to confidentiality that may result.

Duty to Warn

In the event that the clinician reasonably believes that the client is in danger, physically or emotionally, to themselves or another person, consent is given to the clinician to warn the person in danger and to contact any person in a position to prevent harm to themselves or another person, including law enforcement and medical personnel. This authorization will expire upon termination of treatment.

By signing Informed Consent and Privacy Practices form, you acknowledged that you have the right to revoke this authorization in writing at any time to the extent the clinician has not taken action in reliance on this observation. You further acknowledge that even if you revoke this authorization, the use and disclosure of your protected health information could possibly still be permitted by law as indicated in the Notice of Privacy Practices section of this form. You acknowledge that you have been advised by the clinician of the potential re-disclosure of your protected health information by authorizing recipients, and that it will no longer be protected by the federal Privacy Rule. You further acknowledge that the treatment provided to you by the clinician was conditioned on you providing this authorization.

Risks of Therapy

Rewards of counseling are well documented, but there are also risks. Clients often learn things about themselves that they like and that they don’t like. Often growth cannot occur until past issues are experienced and confronted, often causing distressing feelings such as depression and anxiety. The success of treatment depends upon the quality of the efforts of both the clinician and client, along with the reality that clients are responsible for the lifestyle choices/changes that may result from treatment.

Policy Agreement

It is RecPlay Counseling Center Policy that you provide 24-hour notice when cancelling or attempting to change your appointment. The fee for a late cancellation or no show for appointment is the full session rate. RecPlay Counseling Center holds the right to render charges for services that include but not limited to consultation correspondence, letter writing, and also court appearances and preparation upon written prior notice in effort to avoid any surprise and/or unannounced fees. Court preparation and court appearances will come with the charge of a full day’s worth of clients – eight (8) client hours at the full rate of $175 per session (grand total: $1,400) due to the clinician having to set aside a day’s worth of clients for court availability for that court appearance. Other fees will be charged at the same rate as a full session, also listed and charged as $175 per service.

It is also RecPlay Counseling Center Policy that it is not a part of any insurance panels and therefore its services can only be utilized as an out-of-network provider by formally requesting in writing the production of a superbill once a year during treatment. RecPlay Counseling Center policy also includes right to send e-mail communication regarding billing communication, which includes statements, receipts, and/or superbills.

Financial Agreement

RecPlay Counseling Center’s fee per hour (standard 45-50 minute session) is $175 that includes all counseling services listed in treatment unless otherwise pre-approved by the Center Director at a reduced rate. It is RecPlay Counseling Center policy to secure electronic payment for services in the highest level of cybersecurity upon scheduling of session and Recplay Counseling Center, also Jordan Yates, is subsequently authorized to receive payment automatically for securing of scheduled session. By checking and/or signing this document, I approve RecPlay Counseling Center’s Financial Agreement for the purpose of ensuring compensation for mental health services delivered.