CLIENT INFORMATION AND CONSENT
Welcome! The following information is for you to read and
review.
Qualifications
I am a Licensed Professional Counselor -Supervisor (#18222). I
received my master's degree in Clinical Psychology from the
University of North Texas at Denton in 1991. I was employed by a
private health services organization for 17 years and have been in
private practice since April 2003. My experience has been in
assisting clients with many issues, including but not limited to:
grief and loss, anxiety, depression, pain management, relationship
conflicts, pre-marital counseling, stress management and building
effective coping skills. My experience has been with individuals,
groups, couples, families, and teens. I am a board approved
supervisor and supervise counseling interns completing requirements
for independent licensure. I am also a provider of continuing
education credits (CEU Provider #1429).
Confidentiality
Discussions between a therapist and a client are confidential. No
information will be released without the client's written consent
unless mandated or permitted by law. Possible exceptions to
confidentiality include but are not limited to the following
situations: child abuse; abuse of the elderly or disabled; abuse of
patients in treatment facilities; sexual exploitation; AIDS/HIV and
other communicable disease infection and possible transmission;
court orders, criminal prosecutions; child custody cases; suits in
which the mental health of a party is in issue; situations where
the therapist has a duty to disclose, or where, in the therapist's
judgment, it is necessary to warn, protect, notify or disclose;
sexual exploitation by a mental health professional or member of
the clergy, a negligence suit brought by the client against the
therapist; the filing of a complaint with a licensing board or
other state or federal regulatory authority; to regulatory
authorities in connection with their compliance or investigatory
responsibilities; to employees or agents of the practice for
operational purposes, to a supervisor if the therapist is under
supervision and for treatment consultations with other mental
health professional when deemed necessary by the therapist.
In the event that the undersigned therapist reasonably believes
that you are a danger, physically or emotionally, to yourself or
another person, by signing this information and consent form below,
you specifically consent for the therapist to contact any person in
position to prevent harm to yourself or another person, in addition
to medical and law enforcement personnel.
Peer Consultation
Counselors monitor their effectiveness with clients and take steps
to improve when necessary. Being knowledgeable about and
maintaining positive relationships with colleagues has the
potential to enhance services provided to clients. Linda W. McCune
LPC is a member of a Peer Consultation Group including other
licensed mental health professionals that meet monthly. The purpose
of this group is to support professional growth, provide continuing
education training, and improve client outcomes. Consultation with
colleagues is a respected and accepted practice in the counseling
field. Information shared in consultation is for professional
purposes only and every effort is made to protect client identity
and to avoid undue invasion of privacy. The client(s) agrees to
discuss any concerns with Linda W. McCune LPC regarding Peer
Consultation.
At your visit you will be asked to indicate an emergency contact
person(s). This information is to be provided at your request for
use by said persons only to prevent harm to yourself or another
person. This authorization shall expire upon the termination of
your therapy with the undersigned therapist.
FOR FURTHER INFORMATION REVIEW THE NOTICE OF PRIVACY PRACTICES
FURNISHED TO YOU BY YOUR THERAPIST (see www.lpccounselor.com) IN
CONJUNCTION WITH THIS CLIENT INFORMATION AND CONSENT DOCUMENT. By
signing this Intake and consent form below you acknowledge review
of a copy of the Notice of Privacy Practices. If you have any
questions regarding confidentiality, you should bring them to the
attention of the therapist when you and the therapist discuss this
matter further. By signing this information and consent form below,
you are giving your consent to the undersigned therapist to share
confidential information with all persons mandated or permitted by
law, with the agency that referred you and the managed care company
and/or insurance carrier responsible for providing your mental
health care services and payment for those services, and you are
also releasing and holding harmless the undersigned therapist for
any departure from your right of confidentiality that may
result.
Contact Information
You consent for the undersigned therapist to communicate with you
by mail, email and by phone at the addresses and phone numbers that
you have provided and you agree to IMMEDIATELY advise the therapist
in the event of any change.
Confidentiality in Couples Counseling
If individual counseling sessions are indicated, I will maintain
confidentiality with each
partner unless it is believed that information given to me is
detrimental to the progress of
couple therapy. If I am given information by one partner (including
phone calls, or email
communication) that appears to be an impediment to progress in
couple therapy, I will
encourage and support the partner with the undisclosed information
to share the
information in a conjoint session. I will not share this specific
information without the
partners consent, but if the partner refuses to share the
information in a conjoint session,
referral to another therapist is indicated. If information given in
an individual session
indicates that treatment outside my professional expertise is
needed I will provide
appropriate referrals.
Marital or Joint Therapy Records
If I participate in couples or joint therapy pursuant to which
joint sessions are held with the undersigned therapist I consent
for the undersigned therapist to maintain a single case file for
all joint sessions and to release all information contained in the
file maintained for joint sessions to any participant in the joint
session upon request by a participant.
Role changes in the Professional Relationship
In the event that the counseling relationship changes from
individual counseling to relationship or family counseling you
have the right to refuse services related to this change, and/or
to request referral for another provider. While there are
benefits to seeing one provider for both individual and
relationship or family counseling there may also be risks.
The client agrees to discuss any concerns and or preferences
regarding counselor role change with the therapist.
Online Video Counseling
The counselor,
Linda W. McCune LPC-S is licensed in
the state of Texas and this license allows provision of counseling
services only for clients who reside in Texas. Client agrees
to provide current place of residence and will alert the counselor
in the event they relocate out of the state of Texas. In the
event that the client relocates to another state, client will be
responsible for locating available services to continue provision
of counseling as needed. Client can request records to be
forwarded to a new provider after completing an authorization for
release of information.
My practice location for telehealth is: 20580 Hillside
Trail, Lindale, Texas 75771. I provide video sessions from
this location.
For identification purposes
You will be expected to provide a copy of your driver's license
and other identity verification documents requested by the
counselor before distance counseling services are provided.
Client voluntarily agrees to receive assessment, care,
treatment, and services through the use of the following
technologies: video counseling utilizing the secure client
portal accessed at www.lpccounselor.com.
There are privacy and security risks and consequences associated
with distance therapy despite policies and procedures in place to
guard against them. The risks and consequences include but
are not limited to interrupted or distorted transmission of data
or information due to technical failure and access or
interception of your protected health information by unauthorized
persons. By signing this disclosure form you acknowledge
the limitations inherent in ensuring client confidentiality of
information transmitted in distance counseling and agree to waive
your privilege of confidentiality with respect to any
confidential information that may be accessed by any unauthorized
third party despite the efforts of the undersigned counselor to
arrange a secure line of communication.
Online video services and care may not be as complete or
effective as face-to-face services. The counselor will
continually assess the appropriateness of distance counseling for
you. If the counselor determines that the client would be
better served by receiving different services, such as
face-to-face counseling, recommendations will be provided.
Communication interruptions
If you are unable to connect with the counselor or are
disconnected during a session due to a technological breakdown,
please try to reconnect. If reconnection is not possible
you agree to reach the counselor at this phone number:
972-824-2121.
Electronic Records
My office utilizes a secure client portal (CounSol.com) that
provides encrypted email communication capability and electronic
record keeping including personal client information, treatment
records, progress notes and initial intake notes. CounSol.com
provides security to client information and records by complying
with the Health Insurance Portability and Accountability Act and
the HITECH Act and utilizing a high level encryption. The following
safeguards are taken:
- CounSol .com servers are housed in Tier-IV data center (Tier 4
data center considered as most robust and less prone to failures)
with SSAE16, HITRUST, ISO 27001 & PCI 2.0 compliance
- PCI (Payment Card Industry) standards applied to our internal
systems and software
- All traffic is required to use SSL (Secure Socket Layer) with
256-bit encryption
- Unique login for all users
- Logging of all user activity
- 256-bit encryption of all sensitive data
- No sensitive information is sent via email, only notifications to
login will be sent
- Data backed up hourly using 256-bit encryption
- Only the therapist (Linda W. McCune LPC) and the client have
access to this information in the secure portal.
- Data stored on the secure portal are maintained electronically
for the office of Linda W. McCune LPC for the duration of active
membership with CounSol.com. In the event that CounSol.com
membership is cancelled, client records will be exported and copied
to a paper file.
- Linda W. McCune LPC maintains a Business Associate Agreement with
CounSol.com specifying breach notification with respect to any
unsecured personal health information within 5 business days of
discovery.
- Confidentiality of client records stored on CounSol.com has
exceptions including permitted and required uses and disclosures of
personal health information that may be made without your
authorization regarding the following: as required by law, public
health authority, communicable disease, health oversight (audits,
investigations and inspections by government regulatory agencies)
abuse or neglect, legal proceedings, military activity and national
security, criminal activity, and to comply with workers'
compensation laws.
Counseling purposes, goals, and risks
Therapy is the Greek word for change. The practice of counseling by
licensed professional counselors is for the purpose of utilizing
interpersonal, cognitive, cognitive-behavioral, behavioral,
psycho-dynamic, and affective methods and strategies to achieve
mental, emotional, physical, and social development and adjustment
throughout the life span. The therapist, using her knowledge of
human development and behavior, will make observations about
situations as well as suggestions for new ways to approach them. It
will be important for you to explore your own feelings and thoughts
and to try new approaches in order for change to occur. You may
bring other family members to a therapy session if you feel it
would be helpful or if this is recommended by your therapist. In
the event that the counseling relationship changes from individual
counseling to relationship or family counseling you have the right
to refuse services related to this change, and/or to request
referral for another provider. While there are benefits to seeing
one provider for both individual and relationship or family
counseling there may also be risks. The client agrees to discuss
any concerns and or preferences regarding counselor role change
with the therapist.
Risks of counseling may include discomfort, as feelings may be
aroused pertaining to current issues. You may learn things about
yourself that you don't like. Often growth cannot occur until you
experience and confront issues that induce you to feel sadness,
sorrow, anxiety, or pain. The success of our work together depends
on the quality of the efforts on both our parts, and the
realization that you are responsible for lifestyle choices/changes
that may result from therapy. Specifically, one risk of marital
therapy is the possibility of exercising the divorce option.
There may be alternative ways to effectively treat the problems you
are experiencing. It is important for you to discuss any questions
you may have regarding the treatment recommended by the therapist
and to have input into setting the goals of your therapy. As
therapy progresses these may change.
Progress with counseling may not be guaranteed as it depends on
many issues including: family interactions, relationship issues,
work related issues, and social support. As a professional
counselor, I will always strive to provide quality care for each
client, and support clients in reaching resolution to the issues at
hand.
The duration of treatment for clients varies. Some clients may need
only a few sessions while some clients may need ongoing care over a
long period of time. Your initial session will involve an
evaluation of your needs and depending on your circumstances
further evaluative sessions may be required. At the end of the
evaluation process the undersigned therapist will be able to
provide you with some first impressions of what therapy may include
and a treatment plan to follow if both you and therapist agree to
work together in therapy. You should evaluate this information
along with your own opinions of whether you feel comfortable
working with the therapist. Therapy involves a large commitment of
time, money and energy, so you should be very careful about the
therapist you select. If you have questions about procedures feel
free to discuss them with the therapist at any time. If you have
doubts your therapist will be happy to help you set up a meeting
with another mental health professional for a second opinion.
Clients can discontinue therapy sessions at any time. It is
recommended that clients participate in a termination session if
they have decided to discontinue therapy. This allows for a review
of progress, available time for closure, and any appropriate
referrals if necessary. The client agrees to communicate to the
therapist their decision to end therapy.
Counselor Client Relationship
Your relationship with the therapist is a professional and
therapeutic relationship. In order to preserve this relationship,
it is imperative that the therapist not have any other type of
relationship with you. Personal and/or business relationships
undermine the effectiveness of the therapeutic relationship. The
therapist cares about helping you but is not in a position to be
your friend or to have a social or personal relationship with you.
If the therapist encounters you in public setting, in order not to
reveal your identity the therapist will not acknowledge your
presence unless addressed by you client first. Gifts, bartering and
trading services are not appropriate and should not be shared
between you and the therapist.
After-Hours Emergencies
Please know that your therapist and The Center do not provide
twenty four (24) hour crisis or emergency therapy services. Should
you experience an emergency necessitating immediate mental health
attention, immediately call 911 or if you are able to safely
transport yourself go to the nearest hospital emergency room for
assistance.
Contacting Your Therapist
Your therapist is often not immediately available by telephone. The
office number, 972.824.2121, is answered by voice mail that the
therapist will monitor from time to time throughout the day.
Although the therapist is typically in the office during normal
business hours she will not take calls when with a client. A
reasonable effort will be made to return any call made during
normal business hours on the same day it is received, weekends and
holidays excepted. Messages left after hours or on weekends or
holidays will normally be returned the next business day. If you
are difficult to reach, please inform your therapist of times when
you will be available.
Email and Text Messages
The undersigned therapist uses and responds to email and text
messages only to arrange or modify appointments. Please do not send
emails related to your treatment or therapy sessions as electronic
communications are not completely secure and confidential. Any
therapy related questions or issues will not be addressed by the
therapist in any electronic communication but will be dealt with
during your next therapy session. Any electronic transmissions of
information by you are retained in the logs of your service
providers. While it is unlikely that someone will be looking at
these logs, they are, in theory, available to be read by the system
administrator(s) of the service providers. You should know that any
emails or texts received from you and any responses sent will
become part of your therapy record. Understand that the only secure
email communication is through the secure portal provided by your
therapist on the website: www.lpccounselor.com
Social Media
Your therapist does not accept friend or contact requests from
current or former clients on any social networking sites. Adding
clients as friends or contacts on these sites can compromise
confidentiality and privacy of both the therapist and the client.
It can blur the boundaries of the professional relationship and are
not permitted.
Cooperation of Client
You shall keep the undersigned therapist advised of your
whereabouts at all times, and provide the undersigned therapist
with any changes of address, phone number, contact information or
business affiliation during the time period which the undersigned
therapist's services are required. You shall comply with all
reasonable requests of the undersigned therapist in connection with
therapeutic treatment. The undersigned therapist may, set
boundaries including forms of client interactions and communication
including ceasing to provide services to you for good cause,
including without limitation: your refusal to comply with treatment
recommendations, the undersigned therapist or staff is
uncomfortable working with you or your failure to timely pay fees
or deposits in accordance with this Intake and Consent Form,
subject to the professional responsibility requirements to which
the undersigned therapist is subject. It is further understood and
agreed that upon such termination of services of the undersigned
therapist, any of your deposits remaining in the undersigned
therapist's account shall be applied to any balance remaining owing
to the undersigned therapist for fees and/or expenses and any
surplus then remaining shall be refunded to you.
Fees for Counseling Services
Fees are payable at the time services are rendered. Failure to pay
fees for counseling
will result in termination of treatment after appropriate notice
and suitable referrals are
provided.
If using health insurance, I am happy to check benefit information
for you. The client is responsible for any deductible, copayments
or coinsurance. The client is also responsible for any unpaid
balance if for any reason your claim is denied by your health
plan.
Cancellations: When you schedule an appointment time, that time is
specifically reserved for you. If unable to keep an appointment,
notification by phone 24 hours before scheduled time is required.
You will be charged a fee of $50.00 for any missed appointments
without 24 hour notice. Third party payments will not cover the
cost of missed appointments.
Fees for court appearance or deposition, if required, shall be no
more than $150.00 per
hour, payable by the client. In the event that a client's records
are ordered released by
subpoena, a charge of $50.00 shall be assessed to the client.
These fees are subject to change upon sixty (60) days prior notice
to you. To ensure proper payment in the event of a no-show and/or
late cancellation, your therapist will request credit card
information as provided by you (the client/legal guardian) at the
time of your visit. You also agree to pay the $20.00 check fee plus
bank fees for any checks that are returned for non-sufficient
funds.
Therapist's Incapacity or Death
I acknowledge that, in the event the undersigned therapist becomes
incapacitated or dies,
it will become necessary for another therapist to take possession
of my file and records.
By signing this professional agreement, I give my consent allowing
another licensed
mental health professional selected by the undersigned therapist to
take possession of my
file and records and provide me with copies upon request, or to
deliver them to a therapist
of my choice.
Scheduling Appointments
Call 972.824.2121, or contact me at counselorlwm@yahoo.com, or
utilize the secure portal on www.lpccounselor.com to schedule an
appointment time. Appointments are available Monday- Friday.
Daytime appointments are available and the last appointment is
offered at 7:00 p.m. Fees for counseling services can be paid with
cash, check, or credit card at the time services are rendered.
Standing weekly appointment times are available as requested and
scheduling allows. If you would like a standing appointment time
please let me know.
Consent to Treatment
I have read the information above and any questions I have were
addressed. I voluntarily
agree to receive mental health services and authorize the
undersigned therapist to provide
such services as are considered necessary and advisable.
By signing this Client Information and Consent form, I, the
undersigned client (or parent), acknowledge that I have read,
understood and agreed to be bound by all the terms, conditions and
information it contains. Ample opportunity has been offered to me
to ask questions and seek clarification of anything unclear to
me.
If you would like a copy of this form for your records please let
me know at the time of your visit and one will be provided upon
request.
If for any reason you are dissatisfied with the services provided
and wish to contact the
counseling board to file a complaint, you may do so at the
following address/phone
number/email:
Texas Behavioral Health Executive Council
1801 Congress Ave. Suite 7.300
Austin, Texas 78701
Tel. (512) 305-7700
1-800-821-3205 24-hour, toll-free complaint system
Enforcement@bhec.texas.gov.
The Council is open Monday - Friday, 8:00 A.M. to 5:00 P.M., but
closed on state holidays.
Linda W. McCune M.S.,
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