A Healing Journey Counseling & Consultation

650 Henderson Drive, Suite 202

Cartersville, GA 30120

INFORMED CONSENT AND AUTHORIZATION

PLEASE READ THE FOLLOWING REGARDING MY TREATMENT POLICIES AND SIGN BELOW:

 1.            Confidentiality: All communication between counselor and client is held in strictest confidence unless:

A.    The client authorizes release of information with a signature and waives this privilege.

B.    The counselor is ordered by a court to release information.

C.   Dependent abuse/neglect is suspected or revealed.

D.   The client appears to pose a direct threat to his/her or someone else’s life (ex. actively suicidal or homicidal).

E.    Patriot Act

 Note:  You will receive a card from your me with all of the possible ways for contacting me. Please note that it may take met 24-48 hours to return your call.  Individuals may contact me using technological resources.  In doing so, they agree to the understanding that cell phone, email and fax communication are not guaranteed confidential methods of communication. When used, the client is, by choice, relinquishing their rights to confidentiality.

2. Regarding children: Children (under the age of 18) are only seen with signed permission from a parent/caregiver who has legal custody of the child. Parents have a right to any and all confidential information regarding your dependent with the exception of raw test data. Because the presence of trust is important in the therapeutic relationship between your dependent and us, it is generally best that we do not share specifics of individual sessions with you. However, you have the right and responsibility to question and understand the nature of your dependent’s treatment plan, and the progress being made toward treatment goals. If your dependent is able to understand the issue of confidentiality, I will discuss with him/her the type of information that will be shared with you. If you have objections to this manner in which information is shared with you regarding your dependent, we will need to resolve these differences before therapy begins.

3.  Court testimony: I am not trained in matters that involve the legal system. If required to testify for court, speak with legal counsel, etc. my fee is $180.00 an hour plus mileage and expenses incurred. I will not testify in divorce custody or mediation. A two hour minimum is charged.

 4.   Case consultation: I occasionally consult with colleagues regarding cases in order to provide clients with the best possible care; in these situations I normally do not disclose client names or other identifying information.

5.    Therapy Treatment: I expect and encourage you to obtain knowledge of the procedures, goals, and possible side effects of psychotherapy. I will try to make our professional relationship one where you will receive the maximum benefit. I will also keep you informed about alternatives to therapy. Therapy may be tremendously beneficial for some individuals. At the same time, there are no guarantees for therapeutic treatment and there are some risks. These risks may include recalling unpleasant events, facing unpleasant thoughts or beliefs, increased awareness of feelings and/or alteration of your ability or desire to deal effectively with others in a relationship. In therapy, major life decisions are sometimes made. As your therapist, I will be available to discuss any of your assumptions, problems or possible negative side effects of our work together. In marital and family therapy, no secrets will be kept among those actively participating in the therapy. If you are using insurance, please note that a diagnosis will have to be provided to your insurance provider in order to submit the claim for payment.

6.    Termination of therapy: Termination of therapy may occur at any time and may be initiated by you as the client or by the therapist. In either event, a final termination session is strongly recommended to explore the termination process itself.  This can provide a constructive and useful conclusion to treatment. Referrals or other suggestions will be offered at that time.

 7.        A Healing Journey Counseling & Consultation is the name for the private practice of Pamela A. Bridgeman, LCSW, who is licensed to practice in the state of Georgia And who abides by the NASW Code of Ethics. I encourage you to raise any concern you may have about the facility, your treatment and billing, or any other issues relevant to the services provided as soon as you become aware of it.

 IF YOU HAVE ANY QUESTIONS, PLEASE FEEL FREE TO ASK.

 I have read and understand the conditions as stated above.  By signing below, I authorize my therapist to begin therapeutic treatment at this time.

Please provide a person to contact in case of emergency and a contact number here:

Emergency Contact:__________________________________Phone #:__________________

Client Signature:___________________________________________Date:_______________

Therapist Signature:________________________________________Date:_________

Print and bring with you to your first appointment