General Information:

The therapeutic relationship is individualized and highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. You will be indicating that you’ve reviewed and agreed to this when signing the intake documents.
Thank you for acknowledging these policies.

Therapeutic Process:

You have taken a positive step by deciding to seek help and support. The outcome of this work depends largely on your willingness to engage in this process, which may, at times, result in emotional discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong emotions of anger, frustration, depression, anxiety, etc. 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. The more open and honest you are with me, the better able I am to assess your situation and concerns and provide services and referrals that meet your needs.

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:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self 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 Counselor 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. 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. If we see each other accidentally outside of the therapeutic 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. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and under Minnesota privacy laws, you have certain rights regarding the use and disclosure of your protected health information. These rights are more fully described in the Privacy Notice that you’ll receive during client intake.

My Commitment

I am committed to providing professional services to all people regardless of race, ethnic background, class, religion, gender, sexual identity, or ability. If I cannot provide the service you need, I will consult with other professionals and refer you to the appropriate resources. I make all recommendations and referrals based on my professional judgment as to what is in the best interests of my client. I do not accept payment for referring people to other providers. When I make referrals, I will discuss the comparative benefits of these recommendations with you. I have met the requirements and training for Licensed Alcohol and Drug Counselor in Minnesota (LADC license # 304099),

Potential Conflict of Interest or Quid Pro Quo

I make all recommendations and referrals based on my professional judgment as to what is in the best interests of my client. I do not accept payment for referring people to other providers. When I make referrals, I will discuss the comparative benefits of those recommendations with you.

Fees, Payments and Cancellation Policies

You have the right to know the cost of professional services before receiving the service. You are being provided with a notice of Fees, Payment & Cancellation Policies and acknowledge the receipt of this when e-signing. If your insurance company is being billed for services that provider determines the billable rate for services. A 24-hour cancellation is required to avoid being charged. 

Your Responsibilities

You are responsible for giving me accurate and complete information that will enable me to assess your situation and concerns. We can then agree upon services that meet your needs. You are responsible for following through on referrals for evaluation and treatment (i.e. medical, psychological, psychiatric).

In the event of an Emergency

You may call or text (218) 609-1100 and leave me a message after hours if I am unavailable. I will return your call as soon as possible. If you are in crisis, please call 911 or call or text the National Suicide Prevention Lifeline at 988.