Service Agreement and Consent to Treat
I look forward to working with you as your Counselor and Imago Therapist. I am deeply committed to helping you create and achieve your vision for your life and your relationships.
Please read this document carefully. At the end of the document, you will be prompted to “Accept” this agreement indicating you have read, understood, and fully agree to give your informed consent and compliance with these guidelines and parameters before starting counseling and therapeutic services for yourself and/or your family.
OUR WORK TOGETHER
I am a Licensed Professional Counselor (LPC) in the state of Missouri. I have a Master of Science Degree from Emporia State University. I am a nationally registered and board-certified Art Therapist (ATR-BC) with the Art Therapy Credentialing Board (ATCB), as well as a Certified Imago Therapist with Imago Relationships International. I have been a therapist since 1993 and became licensed in the state of Missouri as a Professional Counselor in 2007.
The counseling services that I provide are individualized based on the needs and preferences of each client, couple or family. Based on your needs I will support you in finding your unique solutions, as well as provide you with therapeutic experiences that are reparative and/or informative. A counseling/therapeutic process has many potential benefits. Each person’s experience is unique and cannot be guaranteed. Benefits most often include things like gaining a new perspective or understanding of a problem or situation, experiencing a sense of relief or resolution due to finding an expressive outlet, and the acquisition of skills that improve communication, coping, and the ability to move toward goals. All types of therapies have risks, including making you more aware of uncomfortable and painful feelings. However, I have found most people find both art therapy and Imago Therapy to be particularly safe ways to release and explore feelings of sadness, guilt, anger, frustration, loneliness, and helplessness.
Together we will explore your feelings and needs, and develop a plan toward obtaining the skills and insights necessary to meet your treatment goals and create that which you desire.
Our work together will include compassionately exploring your life experiences and the impact they have had on you. We will gain insight into your patterns and beliefs. I will help you find ways to allow your most authentic self unfold and feel safe to more fully express. During sessions, we will strive to find the behaviors or actions you can take to support your vision for your life and your relationships. The benefits you experience will be a direct result of your intentionally implementing new insights into your daily life. I will help you both identify and pace your transformation.
I will provide you an emotionally safe and encouraging environment for exploration. Your part will be to cultivate openness and honesty with yourself, as well as those whom you are seeking to have authentic connections with. You agree to commit yourself to grow and establish intentions that are truly meaningful to you, as well as actions that are self-supportive.
EMERGENCIES OR NEEDS BETWEEN SESSIONS
If you are having a clinical emergency and feel safe to wait for me to return your call, you may call me at 816-359-1885. If you are experiencing a clinical emergency that requires immediate assistance, you agree to obtain support from one of the following available sources by calling your physician, calling your psychiatrist, calling Access Crisis Mental Health Intervention 888-279-8188, going to your local emergency room, or calling 911.
SYSTEM OF MONEY:
You agree to take financial responsibility for session times. If you are unable to attend a scheduled session, you agree to give two days of notice. If you fail to give a minimum of 24 hours notice, you understand that you will be responsible for a $50.00 late cancelation fee.
PRIVATE CLIENT ACCESS
I may be referring you to special resources to help you apply learning, which will be delivered to you through a secure and confidential “Private Client Website." You will be given a unique username and password. You may access this “Private Client Website” area to access resources and complete documents. I will provide you with the access information and further instructions once we begin our work together.
I agree to have access to the private client website and understand that I will receive email notifications.______________________________________
CONFIDENTALITY
Please carefully read the Notice of Privacy Practices regarding release of information regarding services you receive from me and your individually identifiable information.
The Notice of Privacy Practice is provided under "Documents" in the Private Portal or you may request a paper copy at any of your in-person sessions.
I am unable to guarantee using electronic communication is confidential. Sensitive information like intake questionnaires and goals for therapy are secure in the Private Client Portal based on username and password and secure pages. The security of the Portal is limited based on your intentionally or unintentionally giving access to your password or computer while in the portal, and these cases cannot be guaranteed by this therapist. Additionally the system does generate email notifications and Tips and Affirmations that are not personal in nature; however, anyone who has access to your email will have knowledge of your receiving email from my office.
I agree to receive Relationship Affirmations and Tips to the email I have provided.______________________________________________
If you have a concern about electronic communication, please notify me to eliminate this aspect of your service. Otherwise, by accepting services from me, you are agreeing to the enhanced benefit of the education and support you will receive through the "Private Client Website" and the weekly Affirmations and Tips.
