Welcome: Before starting your counseling, it is important to know what to expect, and to understand your rights as well as commitments. This consent form is an attempt to be as transparent with you as I can about the counseling process, so you are fully informed prior to starting your journey.

What to Expect from Counseling: Psychotherapy is a process of opening up about your life experiences and your genuine thoughts and feelings in order to increase your self-awareness of psychological and emotional conflicts that keep you stuck in unwanted patterns. My approach to counseling is short-term dynamic, strengths-based, emotion-focused, and parts of the self-focused. These approaches focus on helping you uncover the root causes and stuck emotions that contribute to current life distress. At times, counseling may involve temporary periods of discomfort as you begin to work through any trauma experience or confront psychological conflicts you have previously been avoiding.

Fees: Individual counseling is billed at the rate of $100.00 for a 50-60 min session.

I, the client, agree to pay the stated fee by cash (with credit card on file) or credit card (I do not accept checks) at the beginning of each session. If I, the client, am prevented from attending my scheduled session and do not cancel my appointment at least 24 hours in advance, I agree to pay the full session fee. This practice of being charged for no-shows or late cancellations is standard practice in the field and takes into account that you are not just paying for services rendered but reserving a time slot which I cannot offer to someone else on short notice.

Online counseling option: Online counseling is a relatively new development in mental health in which counseling is provided over the internet through a secure HIPAA compliant video portal. Although in-person counseling develops a more personalized connection, time constraints, distance, and other life situations can get in the way. I have fiber optic internet, limiting attenuation and preventing session interruptions. If you choose video counseling, it is recommended that you have quality internet service (not cellular). Full session fees will be charged regardless of any technical problems that cause any interruptions in your session.

Insurance: I do not accept payment directly through health insurance plans. However, some insurance companies may reimburse part of your counseling expenses if you have out-of-network coverage for behavioral or mental health. Upon request, I am happy to provide you with a receipt that you can include when filing an insurance claim with your insurance company. Out-of-network reimbursement is often contingent on receiving a medical or mental health diagnosis and certain diagnoses may not qualify. I do not accept responsibility for collecting payment from your insurance company and cannot guarantee that you will be reimbursed or that you will qualify for a reimbursable diagnosis. Please contact your insurance provider to find out if you have out-of-network coverage and bring any necessary forms to your first appointment.

Confidentiality: The information you share with me during counseling sessions is considered confidential information and is protected by state law. As a mental health counselor, I cannot reveal to third parties whether or not you are a past or current client of mine and cannot disclose any of the information you discuss during our sessions without first obtaining your written consent to do so.

In the following instances, however, I may be mandated or allowed to share information without your written consent: 

- If you talk about events that lead me to believe that a child under the age of 18, an elderly person, or an otherwise-abled person is at risk for emotional, physical or sexual abuse, neglect, or exploitation, I am required by NY State law, as a mandated reporter, to make a report to New York Family and Protective Services with or without your consent.

- If you are not yet 18 years of age, your parents or legal guardians may have access to your records and may authorize the release of information to other parties on your behalf.

- If you disclose sexual misconduct by a previous counselor/therapist, I am required to make a report to the licensing board governing the license of the therapist.

- If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena.

- If I need to cooperate with legal actions against a mental health professional by a licensing board.

- If you submit an out-of-network health insurance claim and the insurance provider needs the information to authorize the counseling or the billing.

- If during your counseling, you are deemed to pose a threat of harm to someone else or to yourself, I am allowed to collaborate with the police or a hospital to take necessary measures to prevent harm from happening. 

Professional Records: All counseling records are kept on a HIPAA-compliant server and under double lock and key. Records will not be released without your written permission except as mandated by law. You are entitled to receive a copy of your records with a written and signed request. Voicemails, emails, faxes, instant messages, and video sessions are kept in the highest confidentiality within the limits of the technology, but confidentiality cannot be guaranteed. Please know that if you call on a landline phone, the conversation may not be confidential. Any computer files kept regarding counseling communications are maintained using secure measures.

Emergencies and regular contact: If you are having an emergency, please call 911 or the 211 lifelines. I keep regular office hours Monday through Thursday from 9:00 a.m. to 5:00 p.m. You can contact me, at no charge, by text, call, or email for any reason relating to counseling and your mental health. However, I am not able to answer calls when with a client. If you abuse this contact privilege through excessiveness or inappropriateness, you will be notified, with a $50 charge for each additional contact regardless of the method.

Email & text notifications: When appointments are scheduled, automatic email/text reminders of your appointment will be sent to you when scheduling your first appointment. By signing this consent form, I agree to receive these notifications, and understand that email/text is not a confidential medium for transmitting health information.

The scope of my services: I am qualified to work with a wide variety of clients and problems, but sometimes I may not have the training needed to address a particular concern. If this is the case, I will discuss it with you and make sure that you receive a referral to another professional who is better qualified to serve you. If you do not want to explore how personality dynamics, personal history, and internal conflicts that may contribute to your problems, I may not be the best counselor for you. Also, if you are having current hallucinations/ delusions, severe thoughts of suicide or self-harm, or extreme Bipolar mood swings you may need more support than I can offer you through weekly psychotherapy, and I reserve the right to refer you to a different or more intensive treatment if I believe you exceed the level of care I can offer.

I, the client, consent to the above terms and agree to mental health treatment with Catherine G. Cleveland, LMHC-P(New York, License), an employee of Global Therapy PLLC.