Forms

Eden Therapies, LLC

Client Consent Form 

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.

Initials:________

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client’s family members communicate to Eden Therapies, LLC that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Eden Therapies, LLC.
In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Eden Therapies, LLC will use his/her clinical judgment when revealing such information. Eden Therapies, LLC will not release records to any outside party unless s/he is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

Initials:________

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Eden Therapies, LLC
becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she 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, she may also contact the person whose name you have provided on the biographical sheet.

Initials:________


LITIGATION LIMITATION: 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 nor your attorney(s), nor anyone else acting on your behalf will call on Eden Therapies, LLC to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

Initials:________

CONSULTATION/SUPERVISION: I, Eden Therapies, LLC, consults regularly with other professionals regarding my clients; however, each client’s identity remains completely anonymous and confidentiality is fully maintained.

Initials:________

E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and email communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Faxes can easily be sent erroneously to the wrong address. Emails, in particular, are vulnerable to unauthorized access due to the fact that Internet servers have unlimited and direct access to all emails that go through them. It is important that you be aware that emails, faxes, and important texts are part of the medical records. Additionally, Eden Therapies, LLC’s emails are not encrypted. Eden Therapies, LLC’s computers are equipped with a firewall, a virus protection, and a password and s/he also backs up all confidential information from his/her computers on a regular basis. Please notify Eden Therapies, LLC
if you decide to avoid or limit in any way the use of any or all communication devices, such as email, cell phone, or faxes. If you communicate confidential or private information via email, Eden Therapies, LLC will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email. Please do not use email or faxes for emergencies.

Initials:_________ 


RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Eden Therapies, LLC profession require that she keep treatment records for at least ___7__ years. Unless otherwise agreed to be necessary, Eden Therapies, LLC
retains clinical records only as long as is mandated by Nevada law. If you have concerns regarding the treatment records, please discuss them with Eden Therapies, LLC. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Eden Therapies, LLC assesses that releasing such information might be harmful in any way. In such a case, Eden Therapies, LLC will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Eden Therapies, LLC will release information to any agency/person you specify unless Eden Therapies, LLC assesses that releasing such information might be harmful in any way.  When more than one client is involved in treatment, such as in cases of couple and family therapy, Eden Therapies, LLC will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

Initials:_________

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Eden at Eden Therapies, LLC, between sessions, please leave a message at the answering service (_702__) _595__-__6818__ and your call will be returned as soon as possible. Eden checks her messages a few times during the daytime only, unless she is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away, please go to an emergency room at the nearest hospital or the Police: 911. Please do not use email or faxes for emergencies. Eden does not always check her email or faxes daily.

Initials:_________

PAYMENTS: Clients are expected to pay the standard fee of $85.00 per 50 minute or $120.00 per 1 1/2 hour session at the time of session unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Eden Therapies, LLC if any problems arise during the course of therapy regarding your ability to make timely payments.  If your account is overdue (unpaid) and there is no written agreement on a payment plan, Eden Therapies, LLC can use legal or other means (courts, collection agencies, etc.) to obtain payment. Legal fees or other services rendered will be at your additional expense.

Initials:_______

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Eden Therapies, LLC will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Eden Therapies, LLC
may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Eden Therapies, LLC is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Eden Therapies, LLC provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

Initials:_______

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Eden Therapies, LLC will discuss with you her working understanding of the problem, treatment plan, therapeutic objectives, and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Eden Therapies, LLC expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

Initials:______

TERMINATION: As set forth above, after the first couple of meetings, Eden Therapies, LLC will assess if she can be of benefit to you. Eden Therapies, LLC does not accept clients who, in her opinion, she cannot help. In such a case, she will give you a number of referrals whom you can contact. If at any point during psychotherapy, Eden Therapies, LLC assesses that she is not effective in helping you reach the therapeutic goals or that you are non-compliant, she is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, she would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Eden Therapies, LLC will talk to the psychotherapist of your choice in order to help with the transition. If, at any time, you want another professional’s opinion or wish to consult with another therapist, Eden Therapies, LLC will assist you with referrals, and, if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, and if appropriate, Eden Therapies, LLC will offer to provide you with names of other qualified professionals.

Initials:______

DUAL RELATIONSHIPS: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Eden at Eden Therapies, LLC’s objectivity, clinical judgment or can be exploitative in nature. Eden/Eden Therapies, LLC will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, military bases, university campus, etc., multiple relationships are either unavoidable or expected. Eden Therapies, LLC will never acknowledge working with anyone without her written permission. Many clients have chosen Eden at Eden Therapies, LLC as their therapist because they knew her before they entered therapy with her, and/or are personally aware of her professional work and achievements. Nevertheless, Eden Therapies, LLC will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise Eden/Eden Therapies, LLC  if the dual or multiple relationship becomes uncomfortable for you in any way.Eden will always listen carefully and respond to your feedback and will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.

Initials:______

SOCIAL NETWORKING AND INTERNET SEARCHES: At times, I may conduct a web search on my clients before the beginning of therapy or during therapy. If you have concerns or questions regarding this practice, please discuss them with me. I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.

Initials:______

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.

Initials:_______

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Eden Therapies, LLC carefully; I understand them and agree to comply with them:

Client’s Name (print)  __________________________________________________________

Signature ____________________________________Date _______________

Psychotherapist’s Name (print) _________________________________________________

Signature ______________________________________________

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