Counseling Relationship: During the time that we work together, we will meet at a mutually agreed uponfrequency for approximately 45 minute sessions. Due to ethical guidelines, our relationship will be strictlyprofessional and not social. The policy of the counseling center and professionalcounselor ethics prohibit the receiptof gifts valued more than $50 by counselors from clients.
Effects of Counseling: At any time, you may initiate a discussion of possible positive or negative effects ofentering, not entering, continuing, or discontinuing counseling. While benefits are expected from counseling,specific results are not guaranteed.Counselingisapersonalexplorationandmayleadtomajorchangesinyourlifeperspectivesanddecisions.Thesechangesmayaffectsignificantrelationships, yourjob,and/oryourunderstandingof yourself.Some ofthese changescouldbe temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achievethe best possible results for you.
Client Rights: You have the right to be provided with professional and respectfulcare. You have the right to knowyour therapist’sassessmentoftheproblem,therecommendedtreatment,andresourcesavailabletohelpdealwithyoursituation. Youalsohavetherighttorefuseoursuggestions.IfIamnotabletoresolveyourconcerns,youmayreferyourcomplaintsto HustonMcComb,LPCSupervisor at( (281)813-7360ortheTexasBoardofExaminersof ProfessionalCounselorsat(512) 834-6658.
Client Responsibilities:1. To be honest, open, a nd willing to sha re your concerns2. To ask questions when you don’t understand orneed clarification 3. To discuss anyreservationsyouhaveaboutyourtreatmentplan4. To follow agreed upon treatment plan5. To report cha nges or unexpected events rela ted to your problem6. Tokeepappointmentswheneverpossibleorcalltocancelwithin24hourspriortoyourappointment.7. To not electronically record any aspect of yours or anyone else’s experience while on TSFW premises
No Show Policy:261. Please cancel or reschedule yourappointment with at least 24 hours notice: There is a waiting list to receive ourcounseling services and whenever possible, we like to offercancelled spaces to our clients in order to shorten thewaiting period.2. If less than a 24 hour cancellation or reschedule is given this will be documented as a “Late Cancellation”appointment.3. Ifyoudonotpresenttotheofficeforyourappointment,thiswill bedocumentedasa“No-Show”appointment.4. Afterthe1st“No-Show/LateCancellation”appointment,youwill receive aphonecallinformingyouthatyouhavebroken our "No-Show/Late Cancellation"policy. TSFW will assist you to reschedule this appointment,if needed.5. Ifyouhave2“No-Show/LateCancellation”appointmentswithinaoneyeartimeperiod,youwill receiveanotherverbalwarning.6. Ifyouhave3"No-Show/LateCancellation"appointmentswithinaoneyeartimeperiod,suspensionorterminationfrom the practice will be suggested. You will be notified by email or letter if the dismissal was approved.
Referrals:Shouldyouand/orIbelievethatareferralisneeded,Iwill providesomealternativesincludingprogramsand/orpeoplewhomaybeavailabletoassistyou.Averbalexplorationofalternativestocounselingwill alsobemadeavailableuponrequest.Youwill beresponsibleforcontactingandevaluatingthosereferralsand/oralternatives.
Records and Confidentiality: All of our communication becomes part of the clinical record. Records are theproperty of The Source for Women. Adult client records are disposed of seven years afterthe file is closed. Minorclient records are disposed ofsevenyearsaftertheclient’s18thbirthday.Mostofourcommunicationisconfidential,butthefollowing limitationsandexceptions do exist: a) I determine that you are a danger to yourself or someone else; b) you disclose abuse, neglect,or exploitation of a child, elderly, or disabled person; c) you disclose sexualcontact with anothermentalhealthprofessional or clergy; d) I am ordered by the court to disclose information; e) you direct me to release your records;or f) I am otherwise requiredbylawtodiscloseinformation.IfIseeyouinpublic,includinginthechurch,Iwillprotectyourconfidentialityby acknowledging you only if you approach me first. Office clerical personnel will onlyhave enough information to schedule appointments,contactyou,andfacilitatethecollection of fees.Inthecaseofmarriageorfamilycounseling,Iwill keepconfidential(within thelimitscitedabove)anythingyoudiscloseto mewithout your family member’s knowledge. However, I encourage open communication between family membersand I reserve the right to terminate our counseling relationship if I judge the secret to be detrimentalto therapeuticprogress.
Emergency Contact: The limited resources of the Counseling Center prevent us from providing crisis interventionor intensive counseling.Ifyouhaveacrisis afterofficehours,pleaseeither:contactyourphysician;callthecrisishotlineat(713)228- 1505; or go to the nearest hospital emergency room. If a hospitalization occurs, please contactthis office as soon as possib le to coordinateyourcare.You mayleaveamessageat(713)780-0030.
Acknowledgement and Consent: Byyoursignaturebelow,youareindicatingthatyouhavereadandunderstoodthisstatement,orthatanyquestionsyouhaveaboutthisstatementwere answered toyoursatisfaction,andthatyouwerefurnished a copy of this statement. By my signature, I verify the accuracy of this statement andacknowledge my commitment to conform to its specifications.