Informed Consent for Treatment

​General Information

Thank you for choosing Cognitive Clarity. Before we begin, I want to let you know that this document is designed to ensure that you understand our professional relationship and provide you with important information about counseling and policies. This disclosure statement complies with the North Carolina Licensed Professional Counselor Act (Article 24 of the NC General Statutes), The Health Insurance Portability and Accountability Act (HIPAA) of 1996, as well as other applicable federal or state laws. For further clarification, please ask any questions to ensure that you understand the various aspects of this document before we begin counseling. When you sign this document, it will also represent an agreement between us. You may terminate this agreement at any time in writing to me. Thank you for dealing with this part of the initial process and legally required document.

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The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

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Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

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1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

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Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

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If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

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All of our communication becomes part of the clinical record. I will keep confidential anything you say as part of our counseling relationship, with the following exceptions: (a) you direct me in writing to disclose information to someone else; (b) it is determined you are a danger to yourself or others (including child or elder abuse), or (c) I am ordered by a court to disclose information. If you would like a copy of your treatment plan, discharge summary, or notes you will be charged $.25 per page.​​

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Session Fees

Fees vary based on choice in therapist, however the following fees are universal. 

Offsite travel fee = $10 (1-15 miles from office); $1 per mile over 15 miles.

Payments accepted are cash, HSA/FSA accounts, credit cards, cash, and checks.

All payment is at the time of session.

If you become involved in a legal proceeding that requires my participation, including any preparation costs that may incur, my hourly fee for service is $200 per hour including a $500 retainer fee.

If you must cancel an appointment, you must give me over 48-hour notice. Otherwise, you will be charged the full session length booked. If any previous sessions haven’t been paid for, client will not be allowed to attend next session until the account has been rectified.​

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Use of Diagnosis

Some health insurance companies will reimburse clients for counseling services, and some will not. In addition, most will require a diagnosis of a mental-health condition and indicate that you must have an “illness” before they will agree to reimburse you. Some conditions for which people seek counseling do not qualify for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of that diagnosis before we submit the diagnosis to the health insurance company. Any diagnosis made will become part of your permanent insurance records.

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Effects of Counseling

As with any intervention, there are benefits and risks associated with counseling. At any time, you may inquire about the effects of entering, not entering, continuing or discontinuing counseling. Risks might include experiencing uncomfortable levels of feelings such as sadness, guilt, anger, anxiety or difficulties with other people. Changes may appear to lead to worsening circumstances for awhile. While benefits are expected from counseling, specific results are not guaranteed. Counseling is a personal exploration and may lead to major changes in your life perspectives and decisions. Together we will work to achieve the best possible results for you. Please note that I do not accept clients whom I cannot help using the techniques that I have available. I enter counseling relationships with hope and optimism, honored to journey with clients.

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Complaint Procedures

Although clients are encouraged to discuss any concerns with their provider, you may file a complaint against us with the organization below should you feel we are in violation of any of these codes of ethics. I abide by the ACA Code of Ethics.

North Carolina Board of Licensed Clinical Mental Health Counselors

P.O.Box 77819 Greensboro, NC 27417
Phone: 844-622-3572 or 336-217-6007 | Fax: 336-217-9450 | Email: complaints@ncblcmhc.org