Client Forms

Family Information

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Informed Consent

  • Client-Therapist Service Agreement

    Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patients' rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very _important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

    Goals of Therapy

    There can be many goals for the therapeutic relationship. Some of these will be long term goals such as improving the quality of your life, overcoming and learning from past experiences or improving self-esteem. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending alcohol or drug use. Whatever the goals for therapy, they will be set by the clients according to what they want to work on in counseling. The therapist may make suggestions on how to reach that goal but you decide where you want to go.

    Risks/Benefits of Therapy

    Therapy is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to therapy. Therapy can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages

    Appointments

    Appointments will ordinarily be 50 minutes in duration as needed and determined by the nature of the therapy. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours' notice. If you miss a session without canceling, or cancel with less than 24-hour notice, you will be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. Cancellations without adequate notice prevent me from filling the time slot with others who could use that time. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

    Confidentiality

    Every effort will be made to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. Consultation with another professional counselor may occur in order to give you the best service. In the event of consultation, no identifying information such as your name would be released. Counselors are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If there is receipt of a court order or subpoena, I may be required to release some information. In such a case, I will consult with other professionals and limit the release to only what is necessary by law.

    Confidentiality and Technology

    Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Facetime, telephone, email or text. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Every precaution to safeguard your information will be taken but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. If you wish, you can make scheduling arrangements via email. I do not do therapy or clinical work through email.

    Record Keeping

    I will keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer.

    Professional Fees

    You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash, check or credit card If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.

    Insurance

    I currently do not accept insurance. I will assist with filing claims for you to be able to be reimbursed. I will provide you with a statement indicating your clinical diagnosis and the CPT code for the service provided which will enable you to file for reimbursement out of network.

    Contacting Me

    I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you feel you cannot wait for a return call or it is an emergency situation, go to your local hospital or call 911.

    Consent to Therapy

    Your signature below indicates that you have read this Agreement and agree to its terms.

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Informed Consent For Couples Therapy

  • Welcome to my practice. Before starting your therapy, it is important to know what to expect and to understand your rights and commitments. This consent form is an attempt to be as transparent as I can about the nature of the couples therapy process, so you are fully informed prior to starting the therapy. Although these documents are long, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

    What to expect: Couples therapy is a process of identifying interaction and communication patterns that are negatively impacting the friendship, intimacy and fulfillment of needs of one or both partners in a relationship. Interventions to increase closeness and intimacy are used to deepen emotional connection and create changes which enhances the couple’s shared goals. Couples learn to replace negative conflict patterns with positive interactions and to repair past hurts.

    Each partner will be expected to honestly examine their own interaction and communication styles, identity and express their own feelings, and are willing to attempt at experimenting with alternative methods of communicating and interacting. Each partner will be helped to further clarify their own values and their own level of commitment to the relationship and the outcome of the therapy may be increased satisfaction with the partnership or increased clarity about the decisions to moving forward.

    Assessment: The first three sessions will be an assessment to determine if the couple is appropriate for couple’s therapy. The first session will last 75 minutes, after which, sessions will be 60 minutes. Longer sessions can be agreed upon before the session begins.

    Cancellation policy: Payment is made after each session by cash, check or credit card. If both or one of you are prevented from attending our scheduled session and do not cancel the appointment at least 24 hours in advance, you will be charged the full session fee. Couples are seen together, so if one person is not able to attend, the appointment will be canceled. The practice for no-shows or late cancellation is standard practice in the field and takes into account that you are not just paying for services rendered, but reserving a time slot which I will not be able to offer to someone else on short notice.

    Confidentiality: When you attend sessions, information you share is protected by strict confidentiality laws enforced both by the licensing board governing my license and state law. Without your written consent and permission, I cannot reveal whether you are a client of mine and cannot any discuss any information from our sessions with a third party.

    The following are exceptions to this rule:

    • If one of you pose an imminent danger to yourself, your partner, or a third person, I am obliged to disclose information to law enforcement personnel or hospital staff to keep you safe and coordinate care.
    • If you talk about events that lead me to believe that a child under the age of 18 or an or an elderly or disabled person is at risk of emotional, physical, or sexual abuse, neglect, or exploration, I am required by law to make a report to Protective Services.
    • If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena.

    The couple is the client: When you attend couples therapy sessions, the couple is considered “the client” and your records therefore belong to both of you. This means that except in the circumstances above, I will need a written consent from both of you to disclose any information from your record to a third party.

    Because the relationship is the primary focus of couples therapy, both partners of a couple must be present for the couple’s session to begin. It is often not in the best interest of the couple to distribute time unevenly between partners or to have unplanned meetings with only one partner present. If one partner is late in arriving or does not show for the appointment, I reserve the right to delay the start of the session or to cancel the session if necessary.

    Limitations to couples therapy: Couples therapy will only be effective in cases where both partners put in a good faith effort to work on their problems and their relationship. Deliberate dishonesty or deceit, unwillingness to introspect and take responsibility for one’s actions, or lack of interest and failure to engage in the couples therapy process by one or both partners will undermine the therapy.

    Couples’ therapy is not advisable in the following situations:

    • If there is active alcohol and/or drug addiction on the part of either or both partners, from either partner’s perspective.
    • If there is serious violence in your relationship, threats by one or both partners that serious violence might occur, or fear of such serious violence on the part of one or both partners
    • If either partner currently has an untreated major mental illness (schizophrenia, recurrent psychotic depression, or bipolar/manic-depressive illness.) This does not include past, successfully treated psychotic episodes.
    • If there is an undisclosed, current affair that you are not willing to disclose (such secrets predict marital therapy failure)
    • If either partner is currently experiencing suicidal or homicidal thoughts, or has a history of serious harm inflicted on him/herself or another person.
    • If the partners engage in litigation that interferes with the therapeutic relationship.

    No secrets policy: As a therapist who is entrusted with information from both partners of a relationship, I have a policy of “No Secrets”, which means that I cannot agree to protect secrets of either partner from the other person. I cannot provide my best therapy if I am asked to keep secrets from one of the partners.

    Between-Session Contact: Please contact me at 713-522-9323 or email me at: lind@lindbutler.com for scheduling or administrative questions. I will typically return calls within 24 hours. I do not discuss clinical matters by phone or without an appointment. Any phone or written communication between meetings will be reviewed with both partners at the beginning of the next session.

    In the event of a clinical emergency, such as acute thoughts of harming oneself or others or experiencing a traumatic life event, you may leave a message on my confidential voicemail indicating the nature of the emergency, and I will return your call as soon as possible. If you feel you are in imminent danger to yourself or others or if you feel that your health is at risk, please visit your nearest emergency room; dial 9-1-1; or call the National Crisis Lifeline, day or night for free immediate support at 1-800-273-8255.

    Termination by the therapist: I reserve the right to terminate treatment under certain conditions which compromise my ability to provide effective services, the client’s ability to benefit from services, or when it is legally and/or ethically appropriate to do so. Such circumstances include, but are not limited to:

    • Three missed appointments or late-cancellations within a six-month period
    • Non-adherence to the treatment plan
    • Non-compliance with practice policies & procedures
    • Refusal to accept recommendations for a higher level of or supplemental care
    • Behaviors that are disrespectful, devaluing, threatening, or otherwise inappropriate.
    • Conduct that compromises the therapeutic relationship
    • Conduct that poses an immediate risk of harm to any person
    • Misrepresentation or omission of pertinent clinical information
    • Non-payment of fees

    We, the client, understand and consent to the above terms, and agree to initiate treatment.

  • Type your full name in the box below as your digital signature.
  • Type your full name in the box below as your digital signature.

Informed Consent For Telepsychological Services

  • Prior to starting video-conferencing services, you must agree to the following:
    • There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.
    • Confidentiality still applies for teletherapy services, and nobody will record the session without the permission from the others person(s).
    • We agree to use the video-conferencing platform, Zoom for our virtual sessions, and the therapist will explain how to use it.
    • You need to use a computer, iPad or smartphone during the session.
    • It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
    • It is important to use a secure internet connection rather than public/free Wi-Fi.
    • It is important to be on time. If you need to cancel or change your tele-appointment, you must notify me in advance by phone or email.
    • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
    • We need a safety plan that includes at least one emergency contact in the event of a crisis situation.
    • If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in teletherapy sessions.
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HIPPA Disclosure

  • In an effort to allow portability in health care insurance, increase resources to combat fraud and abuse, encourage electronic health care transactions and to create a national patient record privacy standard, Congress enacted the Health Insurance Portability and Accountability Act of 1996. This Act (known as HIPPA) created privacy standards, superceded a multitude of differing state laws and imposed requirements on all health care providers.

    HIPAA applies to any health care provider who transmits any health information in electronic form. Health care includes preventive, diagnostic, therapeutic, counseling, and related services, assessments or procedures with respect to the physical or mental condition.

    Health information includes any information, whether oral or recorded in any form or medium, that relates to the past, present or future mental health or condition of an individual.

    A health care provider that either provides treatment, and either maintains or uses individually identifiable health information may not use or disclose protected health information except as permitted by the regulations.

    A health care provider must make reasonable efforts to limit improper disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use disclosure or request.

    The act and ensuing regulations include mental health records. While psychotherapy notes are protected under HIPAA and the Texas Medical Records Privacy Act this does not mean that all psychotherapy records are excluded from required disclosure. Psychotherapy notes are generally exempt from subpoena and unwanted disclosure. It also does not mean they will not be requested or that you cannot authorize the disclosure. In certain circumstances information must be disclosed and in certain situations you are authorized to disclose or may seek that I resist unwanted disclosure. If this happens, we will need to discuss what rules apply and come to a decision on how it should be handled.

    If you want to authorize a disclosure in the future you will be provided a consent in plain language. I will not use or disclose protected information without a valid authorization.

    Limited and relevant disclosure and use is permitted when it is required by law. Some of these circumstances include, public health activities such as aversions of serious threats to health or safety or reports of child abuse or neglect to a public health authority or other appropriate government authority; or of abuse, neglect or domestic violence of the individual agrees or the provider, in the exercise of professional judgment, believes the disclosure is necessary to prevent serious harm to the individual or other potential victims.

    If you become involved in a Judicial or Administrative Proceedings, there are some circumstances in which a health care provider may be compelled to disclose otherwise protected information. If I receive a subpoena, I will let you know as soon as practicable and we will discuss further the legal requirements and options of how to respond.

    Reviewed and Acknowledged:

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Consent for the Release of Confidential Information

  • I understand that my records are protected under Federal and State Confidentiality Regulations. This authorization may be withdrawn at any time in writing except to the extent that the person who is to make this disclosure has acted on reliance on it. Upon revocation of consent, further Release of information shall cease immediately. I further acknowledge that the information to be release was fully explained to me and is given of my own free will.
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