Service Agreement and Informed Consent for Couple
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 relationship.
Please read this document carefully. The purpose of this document is to familiarize you with the benefits and risks of Imago therapy and the unique aspects of the services I provide. At the end of this 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 as a couple.
OUR WORK TOGETHER
I am a Licensed Professional Counselor (LPC) in the state of Missouri. I am a Certified Imago Therapist with Imago Relationships International, as well as a nationally registered and board certified art therapist (ATR-BC) with the Art Therapy Credentialing Board (ATCB). I have been a therapist since 1993 and became licensed in the state of Missouri as a Professional Counselor in 2007. In 2007 I decided to specialize in relationships and carefully researched certification programs beyond my Master of Science degree that would best qualify me to help couples. I chose the Imago theory developed by Dr. Harville Hendrix due to the effectiveness and practical applicability of the interventions. The theory is consistent with my own belief that each individual has an inner propensity toward growth, healing, and loving relationships if empowered with the tools and support.
During Imago Therapy sessions you will experience and learn a model for empathetic communication that will improve your connection in important relationships, while at the same time benefiting from the guidance of a seasoned therapist. While each couple's experience is unique you can expect to gain a new understanding of your interactions, your own needs, and the needs of your partner. You will acquire new skills to improve communication, soothe yourself, soothe your partner, and work as a team toward a joint vision. Couples I work with often report things like learning to quickly recover and reconnect when disagreements or triggers occur, and feeling heard and valued by their partner. All types of relational therapies have risks including making you more aware of uncomfortable feelings, and/or unresolved childhood issues. However, I have found most people find the structure of Imago therapy and the support of an Imago Therapist to be a particularly safe way to release and explore feelings and triggers, and find new ways to access inner and outer support.
Imago Therapy will give you a new experience of communication. You will have the opportunity to begin integrating that experience into your daily life. With the practice obtained during sessions you will find the quality of your interactions greatly improve. You will gain insight into your patterns and beliefs. During sessions, we will strive to find the behaviors or actions you can take to support your vision for your life and your relationship. 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 your partner. You agree to commit yourself to growing and establishing intentions that are truly meaningful to you, as well as actions that are supportive to the relationship.
If you are receiving Imago Couples Therapy please understand that both you and your partner must attend all sessions together. Learning how to honestly communicate emotions, thoughts, opinions and beliefs requires risk-taking, patience and commitment; and is best achieved through collaboration of both partners.
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 assistant 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.
THE 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 48 hours notice you understand that you will be responsible for a 50.00 missed session fee.
Imago Couples Therapy is 110.00 per hour. You may choose to commit to ten hours of therapy and pay in full 1,000 for a savings of $100. You may pay the balance of the 1000.00 prior to the first session, at the first, or at the second session. The experts recommend ten to twelve sessions minimum to solidify a lasting change in the quality of your relational interactions.
PRIVATE CLIENT ACCESS
You will have access to a secured and confidential “Private Client Website”. You will be given a unique username and password. As a couple you will share your username and password and will have identical access to information and logs from this therapist. 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 a private client website, which will include receiving email notification of private logs.____________________________________
CONFIDENTIALITY
There are some situations where I am required to disclose information without either your consent or authorization. These situations are rare for most therapists, and very unlikely in the case of couples who are not receiving services based on a medically necessary diagnosis. If you think you are at risk for any of these situations please discuss your situation at the beginning of treatment. I prefer to have your specific consent prior to ever releasing information.
- A judge may require I testify in legal situations. I am not trained to testify in legal situations and if you believe our work together might be relevant in future legal proceeding let me know immediately.
- The law mandates me to report any suspected abuse of a child, elderly person or disabled person.
- I must also take action if my client becomes a threat to himself or herself or someone else. This may include calling the police, helping them seek hospitalization, contacting family members or others who can help provide protection.
- If a government agency is requesting the information for health oversight activities, I may be required to provide the requested information. Examples include: public health authorities, coroner or medical examiner, military/veteran’s affairs agencies, law enforcement, or for national security purposes.
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend myself.
- Worker’s compensation cases may require records to be submitted to the Chairman of the Worker’s Compensation Board.
I do administrative assistance who also maintain the confidentiality of my clients.
An expanded description of my Notice of Privacy Practice is in the Private Portal. You may also request a paper copy at any of your in person sessions.
Professional Records
Both law and the standards of my profession require that I keep Protected Health Information about you, as well as a Clinical Record. Your progress is documented in private logs that you will have access to through the "Private Client Website". This is a unique benefit that I provide and I have found it to effectively help couples stay on track with the work together and maintain momentum. You will receive a notification of new logs from this therapist in the email you have provided.
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, and/or access to your computer while in the portal, and in these cases confidentiality cannot be guaranteed by this therapist. Additionally the system does generate email reminders and notifications, Affirmations and Tips that are not personal in nature however any one who access to your email may gain knowledge of your receiving email form my office.
I agree to receive Relationship Affirmations and Tips through my email.____________________________________________________
If you have concern about electronic communication please notify me to eliminate this aspect of your service. Otherwise by accepting services form me your are agree to the enhanced benefit of the education and support you will receive through the "Private Client Website" and the weekly Affirmations and Tips.
