Informed Consent to Assessment and Treatment
FAMILY COUNSELING SERVICE OF NNY is a licensed counseling practice that has provided services to the community since 1958. Our staff consists of five (5) Licensed Mental Health Counselors (LMHC), one (1) Marriage and Family Therapist and one (1) completing her hours under supervision to become a LMHC by mid-2022. All are licensed in New York State.
We value our relationships with our clients and believe that such relationships are crucial to the healing process. We believe in a wellness model that helps our clients empower themselves by focusing on what works for them and not on a systematic approach that provides generic procedures for working on a treatment.
PURPOSE OF THERAPY:
The purpose of therapy is to explore the areas of my life that are problematic for me. This may include troubling thoughts, feelings, and/or behaviors. My therapist will always treat me with respect and empathy and will seek to assist me with finding balance and peace in my life. How much I get out of therapy will depend on how much I put into it. I will be asked to discuss thoughts, feelings, behaviors, and past experiences, which may be difficult for me at times. I understand that my therapist will ask questions, listen, and suggest a plan for improving these problems. It is essential that I am open and honest and feel comfortable discussing issues that are bothering me. Together, my therapist and I will develop therapeutic goals. I may be asked to complete homework assignments, which will assist me in reaching my therapeutic goals. I am aware that my therapist will gauge my progress and discuss with me how I am doing and provide an estimated length of treatment, if requested. If my therapist feels that she can no longer assist me in my therapeutic journey, she will inform me of this determination, and may refer me to another clinician.
CHILDREN'S THERAPY:
Both parents are entitled to access and understand their child's treatment unless their child's therapist is provided with legal documentation (ex. court orders) limiting their access or communication. In situations where both parents are not present, and a court order does not prohibit their communication, it is expected that both parents will talk with one another about their child's treatment and develop a communication plan with their child's therapist prior to the course of treatment.
LIMITS OF CONFIDENTIALITY:
The contents of the therapeutic session are confidential; however there are some limits of confidentiality.
1. When there is risk of imminent danger to another person, my therapist is required to take necessary steps to prevent such danger.
2. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse or is being neglected, my therapist is legally required to take steps to protect the child or elder, and to inform the proper authorities.
3. When my therapist feels that I am doing things that could cause harm to myself or someone else, she will use her professional judgment to decide what notifications need to take place.
4. When a valid court order is issued for medical records, my therapist is bound by law to comply with such requests.
5. If I am under 18 years of age, my therapist will provide general updates to my parent/guardian on how I am progressing, but will keep the details of our therapeutic sessions confidential.
6. There may be times when my therapist consults with other mental health professionals regarding issues/content areas that I share with her in session; however my therapist will not give away any identifying information (such as my name) in these professional consultations.
7. My therapist will only release information to outside parties (schools, teachers, hospitals, therapists, doctors, psychiatrists etc.) if I (or my legal guardian) provide my therapist with written consent. In emergency situations, I (or my legal guardian) may provide my therapist with verbal consent to release information.
RECORDKEEPING:
I understand that my therapist is required to engage in record-keeping. These records can be subpoenaed by a court, in which case, my therapist would be required to produce them. If I am under 18 years of age, my guardian can request to see these records; however my therapist would discourage my parent/guardian from requesting these documents. As the client, I also have the right to request copies of these records. My therapist can use her professional judgment when these requests are made and can refuse to release records if she feels that doing so would cause harm.
PAYMENT POLICIES:
If I have health insurance, I agree that Family Counseling Service ("FCS") will bill the insurance company and will accept payment from my insurance company at their rates for the services. I agree that any insurance carrier with whom I have a policy shall direct to Family Counseling Service any benefits and payments related to services rendered to me by FCS providers. I authorize and consent that Family Counseling Service may provide my insurance company with any and all necessary information, including therapist notes, requested in connection with its review and consideration of the claim for payment of benefits.
I am responsible for payment of all charges not covered by insurance, and any and all co-pays, coinsurance, deductibles, and any other payments due at the time of service. If I pay out of pocket ("self-pay"), I may have a credit/debit card on file with Family Counseling Service, which I agree to be charged for any payments due (including missed appointment charges). If my insurance company, policy or plan changes for any reason, I am responsible for promptly notifying Family Counseling Service of that change. If insurance is terminated or benefits are reduced for any reason, I acknowledge that I am responsible for the entire cost of the session as well as any remaining balance on my account.
THERAPEUTIC RELATIONSHIP:
A healthy therapeutic relationship with appropriate boundaries is essential for positive growth and change. For that reason, my therapist will not engage in any friendships, contractual relationships, or solicitations with her clients. Since my therapist must maintain strict confidentiality, she will not acknowledge her clients if she sees them in public unless her client chooses to acknowledge her.
PHONE CALLS, CONSULTATIONS, WRITTEN CORRESPONDENCE, APPEARANCES:
If during the course of my treatment or after termination, I am in need of a written report, phone call/consultation with me or to coordinate services with another provider, written correspondence, for my therapist to appear in court on my behalf etc., I will need to compensate my therapist for her time on a prorated basis. The rate is disclosed in the "OFFICE FEES AND POLICIES" form that requires a signature.
ELECTRONIC COMMUNICATION CONSENT
I consent to Family Counseling Service ("FCS") therapists or staff communicating with me via mobile phone, video, text (or SMS) messaging, email and any other kind of online communications. I agree that FCS can reach me at any time through electronic communications to remind me of appointments or let me know of any changes to them. I also understand that FCS can employ and use a third-party automated system to reach out to me to "confirm", "reschedule", or "cancel" an appointment.
TERMINATION:
As a client, I have the right to terminate treatment at any time. However, I am still responsible for paying any remaining balance on my account.
FAMILY COUNSELING SERVICE OF NNY is a licensed counseling practice that has provided services to the community since 1958. Our staff consists of five (5) Licensed Mental Health Counselors (LMHC), one (1) Marriage and Family Therapist and one (1) completing her hours under supervision to become a LMHC by mid-2022. All are licensed in New York State.
We value our relationships with our clients and believe that such relationships are crucial to the healing process. We believe in a wellness model that helps our clients empower themselves by focusing on what works for them and not on a systematic approach that provides generic procedures for working on a treatment.
PURPOSE OF THERAPY:
The purpose of therapy is to explore the areas of my life that are problematic for me. This may include troubling thoughts, feelings, and/or behaviors. My therapist will always treat me with respect and empathy and will seek to assist me with finding balance and peace in my life. How much I get out of therapy will depend on how much I put into it. I will be asked to discuss thoughts, feelings, behaviors, and past experiences, which may be difficult for me at times. I understand that my therapist will ask questions, listen, and suggest a plan for improving these problems. It is essential that I am open and honest and feel comfortable discussing issues that are bothering me. Together, my therapist and I will develop therapeutic goals. I may be asked to complete homework assignments, which will assist me in reaching my therapeutic goals. I am aware that my therapist will gauge my progress and discuss with me how I am doing and provide an estimated length of treatment, if requested. If my therapist feels that she can no longer assist me in my therapeutic journey, she will inform me of this determination, and may refer me to another clinician.
CHILDREN'S THERAPY:
Both parents are entitled to access and understand their child's treatment unless their child's therapist is provided with legal documentation (ex. court orders) limiting their access or communication. In situations where both parents are not present, and a court order does not prohibit their communication, it is expected that both parents will talk with one another about their child's treatment and develop a communication plan with their child's therapist prior to the course of treatment.
LIMITS OF CONFIDENTIALITY:
The contents of the therapeutic session are confidential; however there are some limits of confidentiality.
1. When there is risk of imminent danger to another person, my therapist is required to take necessary steps to prevent such danger.
2. When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse or is being neglected, my therapist is legally required to take steps to protect the child or elder, and to inform the proper authorities.
3. When my therapist feels that I am doing things that could cause harm to myself or someone else, she will use her professional judgment to decide what notifications need to take place.
4. When a valid court order is issued for medical records, my therapist is bound by law to comply with such requests.
5. If I am under 18 years of age, my therapist will provide general updates to my parent/guardian on how I am progressing, but will keep the details of our therapeutic sessions confidential.
6. There may be times when my therapist consults with other mental health professionals regarding issues/content areas that I share with her in session; however my therapist will not give away any identifying information (such as my name) in these professional consultations.
7. My therapist will only release information to outside parties (schools, teachers, hospitals, therapists, doctors, psychiatrists etc.) if I (or my legal guardian) provide my therapist with written consent. In emergency situations, I (or my legal guardian) may provide my therapist with verbal consent to release information.
RECORDKEEPING:
I understand that my therapist is required to engage in record-keeping. These records can be subpoenaed by a court, in which case, my therapist would be required to produce them. If I am under 18 years of age, my guardian can request to see these records; however my therapist would discourage my parent/guardian from requesting these documents. As the client, I also have the right to request copies of these records. My therapist can use her professional judgment when these requests are made and can refuse to release records if she feels that doing so would cause harm.
PAYMENT POLICIES:
If I have health insurance, I agree that Family Counseling Service ("FCS") will bill the insurance company and will accept payment from my insurance company at their rates for the services. I agree that any insurance carrier with whom I have a policy shall direct to Family Counseling Service any benefits and payments related to services rendered to me by FCS providers. I authorize and consent that Family Counseling Service may provide my insurance company with any and all necessary information, including therapist notes, requested in connection with its review and consideration of the claim for payment of benefits.
I am responsible for payment of all charges not covered by insurance, and any and all co-pays, coinsurance, deductibles, and any other payments due at the time of service. If I pay out of pocket ("self-pay"), I may have a credit/debit card on file with Family Counseling Service, which I agree to be charged for any payments due (including missed appointment charges). If my insurance company, policy or plan changes for any reason, I am responsible for promptly notifying Family Counseling Service of that change. If insurance is terminated or benefits are reduced for any reason, I acknowledge that I am responsible for the entire cost of the session as well as any remaining balance on my account.
THERAPEUTIC RELATIONSHIP:
A healthy therapeutic relationship with appropriate boundaries is essential for positive growth and change. For that reason, my therapist will not engage in any friendships, contractual relationships, or solicitations with her clients. Since my therapist must maintain strict confidentiality, she will not acknowledge her clients if she sees them in public unless her client chooses to acknowledge her.
PHONE CALLS, CONSULTATIONS, WRITTEN CORRESPONDENCE, APPEARANCES:
If during the course of my treatment or after termination, I am in need of a written report, phone call/consultation with me or to coordinate services with another provider, written correspondence, for my therapist to appear in court on my behalf etc., I will need to compensate my therapist for her time on a prorated basis. The rate is disclosed in the "OFFICE FEES AND POLICIES" form that requires a signature.
ELECTRONIC COMMUNICATION CONSENT
I consent to Family Counseling Service ("FCS") therapists or staff communicating with me via mobile phone, video, text (or SMS) messaging, email and any other kind of online communications. I agree that FCS can reach me at any time through electronic communications to remind me of appointments or let me know of any changes to them. I also understand that FCS can employ and use a third-party automated system to reach out to me to "confirm", "reschedule", or "cancel" an appointment.
TERMINATION:
As a client, I have the right to terminate treatment at any time. However, I am still responsible for paying any remaining balance on my account.