INFORMED CONSENT FOR PSYCHOTHERAPY, COUNSELING, OR COACHING SERVICES CONDUCTED BY Charles A. Hughes, MA, LCPC
PROCESS OF THERAPY AND EVALUATION
People come into therapy wanting to “feel better” or “behave in more effective ways.” It is important to understand that change is usually not comfortable all the time. Trying new behaviors can cause anxiety, fear, frustration.
I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged, or disappointed.
Finally, change is not a straight line. We may take side-trips down roads that you did not expect. You will need to have some trust in yourself and commitment to getting past what appears to be a setback. As in most aspects of life, nothing worthwhile comes easy.
WHAT IS MY ROLE?
As your therapist, counselor or coach, my role is to help you get where you are going. I may make suggestions or give you homework, but ultimately my job is not to tell you what to do but to help you figure that out.
The key to success in psychotherapy or life coaching is a common goal or goals known as a therapeutic alliance. These goals are set by you and me by mutual agreement. My assumption is that we are always working on your goals and I expect you to know what your goals are. I encourage you to keep a list of goals and to discuss your progress. Goals need to be clearly stated and I will help you do that. You may not have a clear idea of your goal at the start. That’s okay.
We are in a professional relationship similar to a doctor/patient or lawyer/client. A “dual relationship” would exist if we socialized together or started a business together.
I do not date or form romantic relationships with clients during or after therapy has terminated – ever. I do not form business relationships with clients outside of therapy. I do not accept gifts from clients – not even small ones.
In addition, I do not socialize with clients outside of therapy. This means I will not attend social events in your life such as parties, weddings, or graduations. I also do not accept invitations to connect or friend clients on social media. Please read my social media policy.
If we see one another on the street or in the community, I will not greet you unless you greet me first. Then I will acknowledge your greeting but will not “stop to chat.” This is meant to preserve your privacy.
TERMINATION AND REFERRAL
During the initial intake process and the first couple of sessions, I will assess if I can be of benefit to you.
If you have requested online counseling, my assessment will include your suitability to psychotherapy delivered via technology.
I do not accept clients who, in my opinion, I cannot help. In such a case, I may be able to offer you referrals that you may contact. Therapy and coaching are voluntary. Either of us may terminate the relationship at any time. If I were to decide I could not help anymore, I would give you notice and let you know why. This rarely happens.
PRIVACY & CONFIDENTIALITY
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.
Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and therapist remain the property of Charles Hughes Counseling Services, PC. Verbatim material from therapy sessions remain in the client record and should never be revealed publically unless both client and therapist agree.
You are not permitted to record our sessions whether in person or online. Doing so is grounds for terminating therapy.
WHEN DISCLOSURE IS REQUIRED BY LAW
Under Illinois law, I am a mandated reporter. I must report to the Department of Children and Family Services any reasonable suspicion of child or elder abuse.
Under Illinois law, I must report threats of harm made by a client to a specific person. If you told me, for instance, that you are going to beat up another person and I hear the threat as being real, I would be compelled to notify the police of this threat.
In addition, under the Illinois Firearm Concealed Carry Act, if I believe you would be a significant risk to the public carrying a firearm, I may be required to report this to the Illinois Department of Human Services. You can view this requirement at http://www.dhs.state.il.us/page.aspx?item=37393.
WHEN DISCLOSURE MAY BE REQUIRED
In Illinois, counselors and psychotherapists do not have a legal privilege (such as doctors and patients do), against being compelled to turn over documents or testify. In some circumstances, I can be compelled by court order to release documents related to counseling and/or testify. If you are involved in or anticipate being in a divorce, custody dispute, or other legal proceeding, I recommend you discuss with your attorney the risks of counseling and psychotherapy. In many cases, the benefits of counseling can outweigh this risk. That is up to you and legal counsel.
HARM TO SELF OR OTHERS
If there is an emergency during our work together, or in the future after termination, in which I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the police, hospital or an emergency contact whose name you have provided.
HOW DO I PROTECT YOUR PRIVACY?
All notes concerning our sessions are stored in encrypted form. Video sessions conducted online are not recorded and are done via a third party vendor, http://www.counsol.com, which complies with HIPAA privacy laws. Counsol.com does not record our sessions.
Except for the situations described above, I will not release information about you or discuss your counseling, therapy, or coaching sessions without a written release signed by you.
I do not store your name in my phone.
I will not discuss your counseling by email. I strongly discourage you from communicating about therapeutic or personal issues via email. Email is stored by third party providers and its security and privacy cannot be assured.
Please be aware that texting is not private. Text messages, like emails, are stored by third parties and therefore can be subject to legal process.
I make every effort to keep all information confidential. Likewise, If we are working online together, I ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends and whether or not confidentiality from your work or personal computer may be compromised.
I encourage you to only communicate through a computer that you know is safe i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails.
I do not record online sessions. You are not permitted to record them either. Doing so may result in the termination of our online sessions.
Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
You understand that if I am compelled to attend court, am deposed, or required to provide documents to any court cases, you agree to pay all expenses related to this work in addition the hourly rate for legal work stated in my fee schedule.
TELEPHONE & EMERGENCY PROCEDURES
If you need to speak with me between sessions to alert me of an emergency, please call 708 445-1898 Your call will be returned as soon as possible. Messages are checked daily (but usually not after 7:00pm CT). Messages are checked less frequently on weekends and holidays. If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 800-784-2433, contact Befrienders.org, dial 911, or go to your nearest local emergency room.
FEE FOR SERVICE AND CANCELLATION POLICY
Current rates for therapeutic services are posted on my website. My practice is “fee for service.” That means that fees are due at the time of your appointment unless you are using your health insurance policy.
Note that use of insurance requires me to report some aspects of our relationship to your insurance company, including date of service, type of service (CPT code) and the diagnosis.
In Illinois, insurance will not typically pay for online counseling or therapy.
In making an appointment, you are reserving time on my calendar. If you cancel an appointment or are not available at the appointment time, you are responsible for the full fee for that appointment.
LIMITATIONS REGARDING ONLINE THERAPY
You as the client understand that distance therapy differs from face-to-face sessions. The differences include a lack of “body language” or other communication cues.
Facial expression and tone of voice may be harder to read.
Technical difficulties can occur such as internet slowdown or modem failure. In such case, I would call you by phone so that we can finish or confirm a new appointment time. Depending on how much of the session was completed, I may refund or credit part of your fee.
You understand that online psychotherapy with me is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts.
As stated previously, if a life-threatening crisis should occur, you agree to contact Befriender’s.org, a crisis hotline, call 911, or go to a hospital emergency room.