334-358-2455
334-491-2456
WELCOME! I look
forward to working with you.
I believe that a clear and open relationship is an
important part of the therapeutic process.
Therefore, I encourage you to bring to my attention anything that you do
not understand or that feels uncomfortable to you in any way.
The sessions are completely confidential EXCEPT when
a. I have
reason to believe that you intend to harm yourself or another person
b. A minor has
been abused or neglected.
(This does not apply to adults working
on abuse/neglect that occurred in their childhood.)
c. I am informed that you have a
communicable disease that is affecting another party without his/her knowledge.
d. I am court ordered to testify
or submit files and records by a judge.
e. I am required to submit information
to insurance providers.
I would like to also inform you of pertinent ethical
standards established by the American Counseling Association Code of
Ethics. The Code states the following:
Multiple Clients
When a counselor agrees to
provide counseling services to two or more persons who have a relationship, the
persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the
relationships the counselor will have with each involved person. If it becomes apparent that the counselor may
be called upon to perform potentially conflicting roles, the counselor will
clarify, adjust, or withdraw from the roles appropriately. (A.7)
Role Changes in the
Professional Relationship
When a counselor changes a
role from the original or most recent contracted relationship, he or she
obtains informed consent from the client and explains the right of the client
to refuse services related to the change.
Examples of role changes include
1.
changing
from individual to relationship or family counseling, or vice versa;
2.
changing
from a nonforensic evaluative role to a therapeutic role, or vice versa;
3.
changing
from a counselor to a researcher role;
4.
changing from
a counselor to a mediator role, or vice
versa.
Clients must be fully
informed of any anticipated consequences (financial, legal, personal, or
therapeutic) of counselor role changes. (A.5.e.)
Couples and Family
Counseling
In couples and family
counseling, counselors clearly define who is considered “the client” and
discuss expectations and limitations of confidentiality. Counselors seek agreement and document in
writing such agreement among all involved parties having capacity to give consent
concerning each individual’s right to confidentiality and any obligation to
preserve the confidentiality of information known.(B4b)
In any case, I will take appropriate action to protect
all clients’ privacy and safety.
Fees for counseling services
Due to difficulties experienced in receiving payments
from insurance companies, please clarify in advance that your insurance will
cover services provided by a Martha B. Ellis, Licensed Professional Counselor,
and that there is no required preferred provider list from which you must
choose. Fees for services are as
follows:
50 minute session $80.00
30 minute session $50.00
Preparation for court per hour $125.00
Court appearances per hour $125.00
Missed appointments $50.00
Cancellation of appointments must be
received a minimum of 24 hours in advance to prevent being charged for
the cancellation or missed appointment.
Client records are maintained for seven (7) years and
destroyed after that time frame.
I understand the above
mentioned ethical guidelines, understand that I am responsible for all fees
associated with counseling services including unpaid insurance claims, and
understand that
_________________________________________is/are
the clients to be served.
__________________ ____________________________________
Date Signature
of Client
__________________ ____________________________________
Date Signature
of Client
__________________ ____________________________________
Date Signature
of Client
__________________ ____________________________________
Date Witness
May 2010