Consent For Treatment
This form will be provided in office by the therapist at the initial intake.
Lidia Belle, MSW, LCSW
Licensed Clinical Social Worker, License Number: 69526
1174 E Central Texas Expressway, Suite 108-5
Killeen, Texas 76541
254-462-9065
Introduction
This Agreement is intended to provide the adult client or child and caregiver (herein “Client”) with important information about the practices and policies of Lidia Belle, LCSW (herein “Therapist”), and to clarify the terms of the professional therapeutic relationship between Therapist and Patient. Any questions or concerns about the contents of this Agreement should be discussed with Therapist prior to signing it. Present Peace PLLC is an independently owned private practice operated by Lidia Belle, LCSW. The services provided at Present Peace PLLC include outpatient mental health services to children, adolescents, adults, and families. Services include evidence-based, trauma informed treatment via EMDR (Eye Movement Desensitization Reprocessing), TF-CBT (Trauma Focused Cognitive Behavioral Therapy), Sand-Tray Therapy, PSB-PBT Problematic Sexual Behavior – Phase Based Treatment for 3–12-year-olds, CFTSI (Child and Family Trauma Symptom Intervention). One or a combination of these treatment modalities may be included in individual therapy, parenting skills training, family therapy, and other forms of effective treatments to help minor survivors of trauma and their families.
Licensee Information
Lidia Belle, LCSW is a licensed clinical social worker legally authorized to practice mental health therapy in the state of Texas. As required by law, licensing information is provided to all clients and caregivers interested in receiving mental health treatment at Present Peace PLLC per the Texas Behavioral Health Executive Council.
Risks and Benefits of Therapy
Psychotherapy is a process in which Therapist and Client discuss a myriad of issues, experiences and memories for the purpose of creating positive change so Client can experience life more fully. It provides an opportunity to understand oneself and any difficulties one may be experiencing better and more deeply. Psychotherapy is a joint effort between Client and Therapist. Progress and success may vary depending upon the issues being addressed, as well as many other factors. Therapy may result in several benefits to Client, including but not limited to less stress/anxiety, fewer negative thoughts/actions, better relationships, more comfort in social/work/family settings, and more self-confidence. Such benefits may require substantial effort by Client, including active participation in therapy, honesty, and openness to change feelings/thoughts/behaviors. There is no guarantee therapy will yield any or all of the benefits above. It may involve some discomfort, including recalling and discussing unpleasant feelings/experiences, and may evoke strong feelings of sadness, anger, fear, etc. At times Therapist may challenge Client’s perceptions and offer different perspectives. Issues Client presents may result in unintended outcomes, such as relationship change. Any decision as to his/her personal relationships is Client’s responsibility. During the therapy process, many find that they feel worse before they feel better; this is normal. Client should discuss any concerns with the Therapist.
Records and Record-Keeping
Client’s personal information will be collected, used, and stored as necessary to ensure the provision of high-quality psychotherapy services and in accordance with the requirements of relevant privacy laws. You have the right to see the notes stored in your file, to ask questions and receive clarification. If you would like to receive a copy of your records, an administrative fee may be charged. Therapist will keep Patient’s records for 10 years after termination of therapy. Patient’s records will then be destroyed in a manner preserving Patient’s confidentiality.
Professional Consultation
Professional consultation is an important component of a healthy psychotherapy practice. Therapist regularly participates in clinical/ethical/legal consultation with appropriate professionals. In such consultations Therapist will not reveal any personally identifying information regarding Client.
Fee and Fee Arrangements
Present Peace PLLC currently accepts private pay for therapeutic services: $150.00 per 60-minute session. Longer sessions may be charged pro rata. Therapist reserves the right to periodically adjust this fee and will notify Client in writing in advance of a fee adjustment. The fee may also be adjusted by contract with insurance or managed care organizations or by agreement with the Therapist. The client is to pay for services at time rendered, by cash, check or credit card. Occasionally Therapist may speak by phone with Client for purposes other than session scheduling. Client will pay the agreed-upon fee (on a pro-rata basis) for calls longer than 10 minutes. Text messages should strictly be reserved for cancellation of sessions or to advise of delays in attending session. No confidential information should be shared via text or email.
My fee for a 90-minute couples counselling session is $175. These fees factor in face-to-face session time as well as out-of-session administrative tasks such as record-keeping, appointment scheduling, and other tasks as Page 3 of 4 required. Payment is due prior to each session. Additional fees may be charged if you require letters or reports to be written on your behalf or for telephone conversations lasting longer than 3 minutes. In such cases, I will inform you and obtain your verbal and written consent in advance of doing any work that would result in additional fees. Nonpayment of fees may result in your account being referred to a collections agency, which may have negative implications on your credit report.
Insurance
Client is responsible for all fees not reimbursed by his/her insurance or managed care company or any other third-party payor. Client is responsible for verifying and understanding the limits of his/her coverage, as well as co-payments and deductibles. Therapist is a contracted provider with Aetna, CIGNA, WellCare, Optum and has agreed to a specified fee. Therapist is soon to be contracted through TriCare, Blue Cross and Blue Shield, and Medicaid. If Client wishes to use benefits of his/her health insurance, Client agrees to inform Therapist in advance. If a portion of Client’s therapy costs are covered by insurance, the insurance company will require, at minimum, diagnosis, and dates of service, and may also require a written progress report and treatment plan. When Client signs his/her insurance claim form, he/she waives the right to confidentiality and grants the insurance company access to his/her records. If Therapist is not a contracted provider with Client’s insurance/managed care company and Client wishes to use his/her insurance, Therapist will provide Client with a statement which Client can submit to a third-party payor to seek reimbursement of fees already paid.
Patient Litigation/Client Privilege
Therapist will not voluntarily participate in any litigation or custody dispute in which Client and anyone else are parties. If Therapist is subpoenaed for records or deposition or court testimony, Therapist will assert the privilege on Client’s behalf until instructed in writing to do otherwise by Client or Client’s caregiver/representative. If Therapist is subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Client, Client and/or Caregiver agrees to reimburse Therapist for time spent for preparation, travel, or other time in which Therapist has made herself available for such appearance at the fee agreed upon by Therapist and Patient via Court Fees section of this consent form. (Children’s Advocacy of Central Texas Client’s Criminal Subpoenas are exempt from some fees associated with aforementioned). Client should be aware that he/she may be waiving psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. The client should address any concerns regarding the psychotherapist-client privilege with his/her attorney.
Clients are strongly discouraged from having their therapist subpoenaed or having them provide records for the purpose of litigation. Even though you are responsible for the testimony fee, it does not mean that the therapist’s testimony will be solely in your favor. Therapist can only testify to the facts of the case and, if qualified to do so by the court, in their professional opinion. Asking a therapist to provide confidential records or testify can damage the trust built in a counseling relationship with a client especially if the therapist is still seeing that client in therapy. If the therapist is subpoenaed to testify or provide records in a case where the client is a child, the therapeutic relationship is effectively ended, and it is likely the therapist may not continue to provide services to that child/family.
If a therapist is to receive a subpoena, then the attorney or office staff will need to call the office and set up a time for the subpoena to be served during office hours. The therapist will request a minimum of 72 business hours notice of any Court appearance so that schedule changes for their clients can be made within a reasonable time frame.
Please note: If a subpoena or notice to meet attorney(s) is received without a minimum of 72 business hours notice, there will be an additional $250 express charge.
When it comes to court action, the following fees are in effect:
Preparation Time (including submission of records): $220/hour (billable in 15-minute increments)
Phone calls: $220/hour (billable in 15-minute increments)
Depositions: $250/hour
Time required in Giving Testimony: $250/hour
Mileage: .56/mile
Time Away from office due to Depositions or Testimony: $220/hour
All attorney fees and costs that are incurred by the therapist as a result of the legal action.
Filing document with the court: $100
The minimum charge for a court appearance: $1500
A retainer of $1500 is due at least 72 business hours before the scheduled court appearance. The remainder of the costs will be billed after the court appearance and will be due upon receipt. If the therapist is subpoenaed and the case is reset with less than 72 business hours notice prior to the beginning of the day of the scheduled subpoena, trial, and/or testimony is not given, then the client will be charged $500 (in addition to the original retainer of $1500 for having to appear in court). All fees listed above are doubled if the therapist has priorly been scheduled to be out of town at the time of the court appearance.
Cancellation Policy
The 53 – 60-minute session is a scheduled block of time provided for therapeutic services. Client is responsible for payment of $25 for missed (“no-show”) session(s) or any session(s) for which Client failed to give Therapist at least 24 hours’ notice of cancellation. Cancellation notice should be left on the Therapist’s voicemail at 254-462-9065 or sent via text. If you need to cancel an appointment for any reason, please give Therapist as much notice as possible. If Therapist needs to cancel an appointment for any reason, I will give you as much notice as possible. If you cancel an appointment on the day of the appointment (i.e., the same day) or do not show up for a scheduled appointment, it will be treated as a “missed appointment.” Exceptions may be made for extenuating circumstances such as a medical emergency). If you are late for an appointment, the session will be shortened by the time by which you are late.
Confidentiality
Information obtained during intake assessment, individual and family treatment is confidential and may not be revealed without written permission of the client or client’s legal representative except where disclosure is required by law. Information is shared among mental health staff and interns at Present Peace PLLC, with Child Advocacy Center of Central Texas if client is being seen by CACCT agency referral and therefore participation in treatment is disclosed to the police department, the Bell, Coryell and Milam County District Attorney’s Office, Scott and White Memorial Hospital and the Texas Department of Family and Protective Services. Other mental health agencies involved may be informed of participation in services only when necessary. In addition, disclosure may be required in the following circumstances:
If there is suspicion of child abuse, molestation, or neglect.
If there is evidence of imminent danger to another specified person.
If there is evidence of imminent self-harm to oneself.
If there is suspicion of elderly or dependent adult abuse.
Required pursuant to a legal process such as a subpoena or court order.
By funding agencies inspecting documents to ensure compliance with regulations.
Office Procedures and Therapist Availability
The mental health service is not an emergency care service facility, and the Therapist maintains office hours of operation. Office hours are Sunday – Wednesday 8:00am – 6:00 pm. Therapist is unable to provide 24-hour crisis service. If Client is feeling unsafe or needs immediate medical or psychiatric evaluation, he/she should call a crisis support service 988, a mobile crisis team 211, Option 8, call 911 or go to the nearest emergency room. If Client leaves a voicemail, message, or text for Therapist after hours, she will get back to you on her next day in office. Note that communications sent via email or other web-based services are not secure as communications conveyed in person or over the phone. As such, do not send me extensive personal information via email or text, as the security and confidentiality of this information cannot be guaranteed. Any personal information should be disclosed in session.
The Therapist’s mission is to provide consistent, effective treatment for all youth, adults, or families coming to receive mental health services. And due to the ongoing waitlist, it is necessary that all active clients make their scheduled appointments consistently. Therefore, in an event where a client/family skips 2 appointments in a row without communication with the therapist prior to the appointment (called a “no show”), the therapist will be required to close the case. Additionally, families will be required to have at least 3 face to face sessions with the therapist (via in-person or telehealth) per month. In the event that the client/family is unable to see the therapist face to face for 30+ days, the case will be closed from services.
Due to the nature of therapeutic work and modeling a supportive community for your youth to process trauma and reach their treatment goals, we do require your attendance on site while the client is receiving services. This is also to help your youth in case of any emergency that may happen during the session. If the waiting room is not the most convenient for you and/or your family, you are more than welcome to remain outside in the parking lot or in your vehicle. Under no circumstances, however, should you leave therapy location while your youth receives services at Present Peace PLLC.
Virtual/Web-Based Sessions
Due to the nature of EMDR with Sand-tray use combined, I find in person sessions are most effective; however, I do offer psychotherapy virtually (via a secure online video-calling platform) in certain instances. The main benefit to virtual psychotherapy is that the limitations imposed by geographical distance and travel times are reduced or eliminated. Some of the downsides to virtual psychotherapy include that some information is lost when conducting therapy via video conferencing services (e.g. body language); internet connection problems or low internet speeds may cause interruptions in the session or result in reduced audio or video quality; and additional precautions may need to be taken to ensure privacy and confidentiality (e.g. making sure nobody around you can hear what you’re discussing during the session). I do not prefer to conduct psychotherapy sessions over the phone. If confidentiality cannot be ensured, the session will be terminated.
Termination of Therapy Services/Withdrawal of Consent
Therapist reserves the right to terminate therapy at her discretion, for reasons including but not limited to untimely fee payment, noncompliance with treatment recommendations, conflict of interest, failure to participate in therapy, or Client’s needs being outside Therapist’s scope of practice or competence. Client also has the right to terminate therapy at his/her discretion well as withdrawal of consent to release information at any time. If you are interested in withdrawing your authorization to release information, you will be required to do so in writing and will take effect the date the therapist receives the written request. All releases of information made prior to the revocation that were made in reliance on this authorization, shall not constitute a breach of this agreement or your right to confidentiality. Therefore, this authorization shall remain in effect until it is expressly withdrawn in writing and received by the therapist. Upon either party’s decision to terminate, Therapist will usually recommend Client participate in at least one termination session to facilitate a positive termination experience and allow both parties to reflect on the work that has been done. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Client.
Release of Information
Please initial the following statements:
__________ If referred by Children’s Advocacy Center of Central Texas, I authorize Lidia Belle, LCSW and Present Peace PLLC to communicate with representatives of the aforementioned agencies listed in this consent regarding all aspects of the services rendered by the Children’s Advocacy Center as contemplated in this authorization.
__________ I authorize Lidia Belle, LCSW and Present Peace PLLC to use any information obtained from me for consultation and instructional purposes, including but not limited to audio/video recordings, clinical notes, artwork, and the results of any clinical testing and evaluations.
__________ I understand that all such information concerning me, and my family used outside of Present Peace PLLC for instructional purposes will be presented in such fashion that it does not disclose the identity of me and my family, except where necessary. Nothing in the Authorization and Agreement shall be construed to affect or hinder (1) the obligation of the staff of Present Peace PLLC to report suspected child abuse to law enforcement as required by state law, or (2) to report statements of intent to harm self or others, (3) to release or provide information pursuant to an order of a court of competent jurisdiction. I understand that my therapist and/or therapy notes may be subpoenaed to the court.
__________ I understand that Lidia Belle, LCSW and Present Peace PLLC does not guarantee any particular result or outcome for the therapy process or because of any other services and/or treatment provided by them to me or my family.
Consent
I agree with the terms of this consent and approve the mental health treatment Lidia Belle, LCSW and Present Peace PLLC for therapy, testing, diagnostic evaluation, and any further mental health services pertinent in the counseling process.
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Client’s Name (Printed)
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Client’s Signature Date
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Client’s Legal Representative’s Name (Printed) Relationship to Client
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Legal Representative’s Signature Date
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Therapist’s Name (Printed) License Title
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Therapist’s Signature Date
Complaints
If you believe your privacy and security rights have been violated, you may file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. All complaints should be submitted in writing. You will NOT be penalized for filing a complaint.
The address for the Office of Civil Rights is:
Office for Civil Rights
U.S. Department of Health and Human Services
1301 Young Street, Suite 1169
Dallas, Texas 75202
(214) 767-4056; (214) 767-8940 (TDD); 214.767.0432 (Fax)
