The purpose of this form is to share some important principles, which guide my counseling process so that your decision to place your child or adolescent into counseling with me can be based on accurate, informed expectations. Please read this carefully and feel free to ask any questions about what you have read or to have further clarification. Informed consent is the parent’s and/or the child/adolescent’s full and active participation in decisions that affect them and freedom of choice based on the information shared. This is a continuous process throughout the counseling relationship. The parent and/or child or adolescent have the right to refuse and/or withdraw from treatment at any time.
Hello, I first want to thank you for selecting me to assist you in renewing your child, yourself, your family, and/or relationships. I am honored to have the opportunity to collaborate with you on a personal level and look forward to our time together. I am a Licensed Mental Health Counselor and completed a Master of Arts in Marriage and Family Therapy from Liberty University in Lynchburg, VA. I have counseling experience with individuals, couples, families, and groups facing mental health, marital, and/or relational challenges.
I appreciate that you have come to me and want to be thorough and specific in helping you and your child/adolescent. I believe that my job is to provide assessment and counseling while working conjointly with you and your child/adolescent to set and help you pursue treatment goals. It is true that in counseling, success depends on the client actively wanting to change. Counseling is not an exact science, and at times the counselor, in consultation with you and your child/adolescent, may need to revise the goals of treatment. Assessment may be carried out during our first session and/or throughout treatment for further clarification of presenting problems. Unless otherwise stated, all counseling sessions are approximately an hour and a half long. The benefits of counseling include gaining an increased understanding of yourself, your child/adolescent, and/or other members of the family, as well as learning practical tools to help you thrive within those relationships and other situations of your life. This insight and practical application is intended to help you and/or your child/adolescent to feel more prepared to deal with conflicts as they arise and more fulfilled with your relationships as a whole. The risks of counseling include the possibility of increased stress for you, your child/adolescent, and/or other family members through the experience of uncomfortable emotions during counseling sessions and as you perform homework assignments. As a result, you could begin to rethink aspects of your life, relationships and consider change.
My fee is $160 per session, typically 55 minutes, payable by cash, check, credit card, or payment app (additional cc processing fee). I am an Out-of- Network provider for most insurance companies and will discuss my payment collection process briefly with you during our first session. A $25 Late Cancellation Fee will be assessed if cancellation notice is not received 24 hours prior to appointment.
Ethically and legally, I am required to keep records of all our contacts. Per federal/state regulations, you and other legal guardians of your child have the right to information generated between us. Explicit permission from any legal guardian must be provided for information to be revealed, unless the law specifies otherwise (see exceptions to confidentiality). Therefore, with written consent of a legal guardian, I will provide information to anyone with a legitimate need. Florida law requires that counseling records be maintained for 7 years. Then, because of space and privacy concerns, records are destroyed in compliance with state law and professional ethics.
The following are legal/ethical exceptions to confidentiality:
In case of suspected abuse (child, elder, and vulnerable populations); In case of danger to self or to others; In case of planning a future crime(s); Legal proceedings when counseling records may be subpoenaed; If a client sues a counselor or makes false charges against a counselor; When the client is a minor; When counseling a client who is terminally ill; When using non-encrypted email (i.e. gmail, yahoo, aol, etc.) or video conferencing (Skype, etc.); In a medical emergency
Counselors who work with children and adolescents have the difficult task of protecting the minor's right to privacy while at the same time respecting the parent's or guardian's right to information. Therapy is most effective when a trusting relationship exists between the counselor and the child/adolescent. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children/adolescents and their parents. However, it is often necessary for children/adolescents to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.
It is my policy to provide you with general information about treatment status. I will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child/adolescent to another mental health professional with more specialized skills, I will share that information with you. I will not share with you what your child/adolescent has disclosed to me without your child’s/adolescent’s consent. At the end of treatment, I will review the sessions in general with you including issues discussed, progress made, and areas likely to require intervention in the future.
Obtaining Parental Consent (please check one):
Parent has sole custody and can give consent
Parents share joint custody and either can give consent. Consent from both is preferred.
Court appointed Sole Guardian of minor and can give consent.
Court appointed Joint Guardians of minor and either can give consent. Consent from both is
Preferred.
Other(Please describe):
Client as a Consumer:
As a client in counseling, you and/or your child/adolescent are encouraged to participate actively and fully in your own treatment. You and/or your child/adolescent are encouraged to follow through with as many homework assignments as are given. In addition, please keep me aware of times when you have not completed, or will not be able to complete, out-of- session assignments so that we can create a new plan. Also, if you feel you do not fully understand something, ask me for clarification. Clients who take an active approach to their treatment are more likely to make therapeutic progress than those who wait passively for things to change.
I, the undersigned, certify that I voluntarily give my consent to attend counseling sessions and participate in the intake assessment interview and/or treatment in the outpatient counseling provided by David Reed, LMHC. By providing my signature below, I acknowledge that I have read, understood, and agreed to counseling services based on all information presented here in this informed consent document. I understand my rights as a client are protected by federal regulations. I acknowledge and fully understand these rights.
I/we consent that my son/daughter/child, , under the age of 18, may be treated as a client by David Reed, LMHC.
Parents: Do not leave the premises while your minor child is with his/her therapist.
Your presence is necessary during your child's visit. In addition, it may be necessary for me to speak with you at some point during your child's session.