WELCOME HOME

I am grateful to be chosen to walk with you at this point in your healing journey. Please let me know if you have any questions after reading this agreement and prior to signing. Once you sign, it will constitute a binding agreement between us. 

SCOPE OF PRACTICE & GOVERNING BODY

The following is an agreement to enter in to the initial intake and treatment process with Nicole D Widman dba Homemaker Counseling, Licensed Clinical Social Worker #120505. My license is regulated by the State of California Department of Consumer Affairs, Board of Behavioral Sciences. If you should need to contact DCA, they can be reached at 800-952-5210. If you have any questions regarding my license or any concern regarding your treatment, please speak with me about it. I will take your concerns seriously and respond with care and respect. 

LIMITS TO CONFIDENTIALITY 

All communications between you and your clinician will be held in confidence unless you provide written permission to release information or except where disclosure tis required by law:

Vulnerable Adults and Children: Stated or suspected abuse of a child or vulnerable adult to the appropriate social service agencies and/or legal authorities. 

Gravely Disabled

Legal Proceeding: When mental state is used as part of legal defense or accusation, or when pursuant to a legal proceeding. 

Duty to Warn: If the client has an intent or plan to harm another person. We are required to inform the intended victim and notify legal authorities. 

Suicide/Self-Harm: Depression is common emotion expressed in therapy, but if a client is feeling hopeless enough to imply or disclose a plan for suicide, steps need to be taken to ensure safety. This would include notifying the legal authorities as well as make reasonable attempts to notify the family.

Minors/Guardianship: Parents or legal guardians have the right to access a minor client’s health information. Age of adult for psychotherapy is 18 years old.  However, per California Law, a minor age 13-17 may initiate their own psychotherapy, without parental consent, under certain circumstances.     

Consultation: Your therapist may seek advice from other professionals. During a consultation, he or she will make every effort to avoid revealing the identity of any client. The other professionals are also legally bound to keep the information confidential. Your therapist may or may not discuss these consultations with you.

RISKS & BENEFITS OF THERAPY

Treatment is approached by employing varying schools of thought including, but not limited to, EMDR (Eye Movement Desensitization Reprocessing), Cognitive-Behavioral (CBT), Psychodynamic, and Family System therapies. EMDR therapy was originally developed to treat trauma symptoms. It utilizes bilateral stimulation for treatment of a variety of symptoms and conditions. Cognitive-Behavioral therapies look at the interaction of thoughts and behaviors while Psychodynamic therapies explore intra-psychic processes and their interplay with interpersonal relationships. Family System therapies view the family as an emotional unit and examines the feedback loop between each individual in the family and the family as a whole. Although the research suggests that these and other treatment approaches can be helpful and result in a number of benefits, please note that therapy may be a challenging process and no outcome can be guaranteed, disruptions to relationships may take place, and discomfort may be evoked. Your therapist is available to discuss these issues, including therapeutic approaches, at any time during your treatment.

THE THERAPEUTIC PROCESS

The first session will be an intake. Once the intake has been completed, we will begin discussing treatment goals and process based on a collaborative process of clinical recommendations and client goals. 

APPOINTMENT POLICY & CANCELLATIONS

Consistency supports the therapeutic process, but we completely understand that things come up and there is flexibility that life warrants. Your therapist will need to be notified if you need to change or cancel yoiur appointment. Cancellations of appointments less than 24 hours in advance and “no shows” will be charged the full fee for the appointment. If you arrive late to your appointment, your appointment will still end at the designated time and you will still be subject to the full fee charge for the appointment. 

COMMUNICATION

Please note, email and text messages, like most forms of electronic communication, are not completely secure or confidential so I cannot guarantee confidentiality of any therapeutic content, including but not limited to information regarding danger to one’s self or others, if communicated through email or text message. Please note, sending an email or text message does not mean your therapist has had the opportunity to read your message. Your therapist will only review and respond to emails or text messages within normal business hours, which are Monday through Friday from 9am to 6pm.  Emails and texts sent outside of normal business hours will generally be responded to either the next business day or as soon as the therapist deems necessary for all non-emergency communication. In case of an emergency, please first call 911 or proceed to the nearest hospital emergency room; then you may contact your therapist about emergency issues.

If you need to contact me between sessions, please leave me a voicemail or email. Text messages are primarily used for appointments. Please contact the following for after-hour support:

Call 911 or go to the nearest emergency room immediately. 

Call (855) 625-4657 to connect with the Orange County Behavioral Health Department. 

Call 988 or text HOME to 741741 to reach The National Suicide Prevention Hotline.

SOCIAL MEDIA

My primary concern is to maintain your confidentiality. Commenting on social media platforms can compromise your confidentiality so I do not respond to clients on any social media platforms. Please use methods of communication above to correspond regarding your sessions and appointments.  

PAYMENT FOR SERVICES & COURT POLICY

Cost for therapy is $150 per (45-minute) session. Payment can be made via cash, credit/debit card or check payable to Nicole D Widman. Insurance is not accepted at this time. This fee is charged for therapy appointments as well as time spend for other agreed-upon professional services, such as report writing, letters, meeting attendance, record review, document/record preparation and telephone calls lasting longer than 15 minutes. Your fee may be subject to an annual increase. There is a $1000 daily charge for preparation and attendance to any legal proceeding. 

If you do not pay your fee, we are legally permitted to contact a collection agency. I, the client, agree to be responsible for the payment of $150 per session (45 minutes) which is payable at the time of the session. I understand that I am responsible for full payment, even though I may be reimbursed by my insurance company. Clients are not permitted to carry a balance of more than two sessions. If you are unable to pay this balance, we will discuss pausing therapy or identifying another solution.

RIGHT TO RECORDS

Records may be requested at any time upon written request, but confidentiality of the records is the sole responsibility of the client once released to you. Records will be stored in a locked file cabinet or by a secured online practice management software system. Records will be kept for 7 years after termination of services. If client is a minor, records will be kept for 10 years and/or up to the age of 25, whichever is furthest out from termination of services. 

TERMINATION OF THERAPY

It is within the client’s right to terminate therapy at any time. The therapist may choose to terminate therapy if the client is threatening or abusive to the therapist, not complying with the treatment plan, not paying for services, or if the therapist believes the client is no longer benefiting from the therapy.  In the event of termination, the therapist will try to provide the client with several referrals, unless the client has already obtained other services or declines to get referrals. It is usually advisable, but not required, to have a termination session to process the work. 

AGREEMENT TO TERMS & CONDITIONS

This agreement cannot be changed except in writing by both parties. By signing below, client acknowledges that they have read, understood, and consent to the terms and conditions of this agreement. Client has had questions regarding its terms and conditions answered. Client agrees to abide by the terms and conditions of this agreement and consents to participate in mental health services with clinician.

TELETHERAPY

Tele-therapy Informed Consent Form

1. Tele-therapy is voluntary. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment. 

2. I may only engage in tele-therapy sessions when I am physically located in California. The healthcare provider will confirm my current location at the start of each session. I agree to engage in sessions only from a private location where I will not be overheard or interrupted, and I will not record any sessions. 

3. The laws that protect the confidentiality of my medical information also apply to tele-therapy.  As such, I understand that the information disclosed by me during the course of my therapy or consultation is generally confidential.  However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in the general Psychotherapy Services Agreement which I received with this consent form.

4. I understand that there are risks and consequences from tele-therapy, including, but not limited to, the possibility, despite reasonable efforts on the part of the therapist, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of my information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and confidentiality cannot be guaranteed. 

5. I understand that tele-therapy-based services and care may not be as complete as face-to-face services, and if the therapist believes I would be better served by another form of therapeutic service (e.g.: face-to-face services) I will be referred to a professional who can provide such services in my area. I understand that there are potential risks and benefits associated with any form of psychotherapy, and that I may benefit from tele-therapy, but the results cannot not be guaranteed or assured. 

6. I accept that tele-therapy does not provide emergency services. During our first session, the therapist and I will discuss an emergency response plan.  If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.  If I am having suicidal thoughts, or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour support. 

7. I understand that I am responsible for providing the necessary computer, telecommunications equipment and internet access for my tele-therapy sessions; the information security on my computer; and arranging a location with sufficient lighting and privacy that is free from distractions or intrusions during my therapy sessions.

By beginning tele-therapy, I confirm that I have read and understand the information in this informed consent, and give my informed consent to receive treatment via tele-therapy.