Consent and Contract for Counseling Services
Welcome to McKay Counseling Inc.
Please read the following information about my professional ethics and business policies. Your signature is an acknowledgement of your agreement to abide by these policies.
About Me
I am a Masters level counselor and a Licensed Professional Counselor in the State of Arkansas. It is important for you to know that I am not a Medical Doctor, Psychiatrist, or a Psychologist. I work with a wide range of ages and populations and use a wide range of techniques based on the client and presenting problem. As a Christian counselor, I try to integrate emotional, physical, and spiritual components to promote the overall well being of my clients.
Counseling Services
Counseling is a powerful treatment. There are some risks as well as benefits. As with any treatment decision, you should be aware of the risks and benefits of counseling. For example, in counseling you may experience uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness or other feelings. You may recall unpleasant memories. In counseling, major life decisions are sometimes made. Changes in relationships, employment or life style may result from participation in counseling. Clients may call into question many of their beliefs and values. Your counselor will be available to discuss any of your assumptions, problems, or possible negative side effects that you may experience in your work together.
The benefits of counseling are many and have been well researched by scientists. People suffering from depression may find their mood lifting. Feelings of fear, anger or anxiety may be relieved. Relationships or coping skills may greatly improve. Personal goals may become clarified. Increased satisfaction from social and family relationships may be experienced. There are no guarantees about the outcome of counseling. As professional licensed counselors, we do not accept clients we do not think we can help. However, we enter the counseling relationship with you with optimism about our program.
Appointments
Appointments are generally 50 minutes. Except for illness or emergencies, a 24-hour notice is required for cancelled appointments. If the appointment is not kept or cancelled without 24-hour notice; you will be charged $50 cancelation fee. This is not coverable by insurance.
Fees for service
Regular sessions of 50 minutes are $150.00, although this may vary. Payment is requested at time of service. Payment may be made by cash, check, or credit card.
Counseling records
Records will be kept online through a program called Therapy Notes. It is my responsibility to protect the information in these records. The records are my property, the information is yours. Because these are professional records, they can be misinterpreted and can be upsetting. If you wish to review your records, you may do that in my office with me present so that we can discuss what they contain.
Insurance reimbursement
Your health insurance policy may provide some coverage for mental health treatment. Remember that we have no role in determining your insurance plan. Please take the proper steps to confirm your benefits and deductibles with your insurer.
Contacting your counselor
In the event that your counselor or their alternate is not available, please contact your family physician or go to the nearest emergency room.
Confidentiality
We will treat all your information with great care. We do not divulge that you are a client or anything about your case without your permission in writing. It is your legal right that your information is kept confidential. The only way that we can release information about you is if you sign a Release of Information form. There are a few legal exceptions to your confidentiality.
1. If your counselor believes that you are at risk of harming yourself or someone else.
2. If your counselor believes that a child, elderly person or disabled person is being abused.
3. If a judge subpoenas records or counselor testimony.
4. If you report sexual exploitation by another mental health professional.
These situations are very rare but it is important that you are aware of these exceptions to confidentiality. Should such a situation occur, your counselor will make every effort to discuss it with you before taking action. In the case of relationship or family counseling, no information will be released without the signed consent of all adults involved in the counseling. No information about minors will be released without parental/guardian consent. There are two situations where your counselor may discuss your case with another counselor. First, if your counselor is going to be away for an extended period. Another counselor will be available should you need care while your counselor is away. The counselor providing coverage will be told basic information about your case. The second situation is consultation with another counselor about cases. NO identifying
information is shared in consultation. Consultation allows us to provide high quality counseling. In both cases, the other counselors are required to keep client confidentiality just as your counselor is.
Generally, your health insurance company will receive only the dates of your appointments, type of service provided, cost and your diagnosis. This information will become a part of your permanent medical record. We CANNOT insure confidentiality of information released to your insurance company. If you have any concerns about the release of information to your insurance company, please speak about your concerns to your counselor.
I acknowledge that I received, read (or have had read to me) and understand the Consent and Contract for Counseling form. I further acknowledge that I have had the opportunity to ask questions about this contract with my counselor. I acknowledge that I am willingly entering into counseling. I agree to take an active role in the counseling process. I understand that no specific promises have been made to me by my counselor about the results of counseling, or the number of sessions necessary for counseling to be effective. I understand that I have the right to speak to my counselor anytime about my progress in counseling. I am aware that I may stop counseling at any time. The only thing that I will be responsible for is paying for the services that I have received. I understand that I may lose other services or have other problems if I stop counseling prematurely. I agree that I will discuss any concerns about my counseling with my counselor before I end counseling. I understand that I must call to cancel an appointment at least 24 hours before the time of the appointment or $50 will be charged to me. I agree that my insurance company or other third party payer may receive information about the type, date and cost of services, as well as my diagnosis. I understand that I am responsible for the payment of fees. I
understand that my counselor may cease treatment if payment for services is not received.