Counseling for a Better Life, PLLC: Consent To Terms
Please read and sign below to agree and state You Understand Terms:
I understand that I am consenting to have a counseling conversation by telephone. This is for general counseling and not a therapeutic counseling services. Therefore, there is no diagnosis, treatment planning, electronic medical processing or any other specialized services. The customer is paying for general information, supportive talk and guidance given at the time of the appointment.
I am 18 years or older.
I understand that Vicki Langemo is a Licensed Professional Counselor in the State of Minnesota and has a Master’s degree in Counseling Psychology from St. Thomas University.
I understand that Vicki Langemo will only be providing counseling conversations by phone and this is not therapeutic counseling. The term counseling refers to professional supportive talk.
I understand that as the client, I am in control of the counseling relationship and may choose at any time to end our relationship.
I understand that if any assignment is given that I disagree with morally, ethically, or emotionally, I have the right not to proceed in that assignment.
I understand that if I am concerned about slow progress or lack of progress I have the right to speak to Vicki about this issue.
I understand that Vicki Langemo is not a medical doctor and does not prescribe medication.
I understand that there are some occasions when there are limits to confidentiality. Here are some of the main exceptions and I can always choose to not disclose this information:
1) If I direct Vicki Langemo to tell someone else in writing or verbally to share my information.
2) Vicki Langemo determines the client poses a threat to self or others.
3) Vicki Langemo is ordered by a court to disclose information.
4) Vicki Langemo suspects child, elderly, and/or handicap abuse.
5) Any sexual misconduct by a previous mental health provider will be reported.
6) Vicki Langemo may disclose your health information when required to do so by law. I have signed the confidentiality statement and understand the limits.
I understand that counseling can improve, as well as, upset the equilibrium in any person and/or family. Vicki will try her best to make counseling a positive experience but there are no guarantees to counseling. Counseling can bring up painful issues. Sometimes clients chose to make big decisions during discussions. Decision-making at its best is an educated guess weighing the pros and cons of each issue but future outcomes can NOT be foreseen.
I understand Vicki is a client-centered counselor, this means she will work with me to determine what issues I wish to work on at each counseling session. She is also has a background in cognitive/ behavioral therapy and may tell me about these types of coping skills. She will try to increase my awareness, notice my thought process while encouraging behavioral and thought changes.
I understand that Vicki may be hard to reach at times because she does not monitor phone messages and emails all the time. If I am of need of help, I understand I can call 911. Crisis Connection, (612-379-6363) or the suicide hotline (1-800-784-2433) or (1-800-273-8255).
I understand that as a human being, Vicki may have health problems or life emergencies that prevent her from making an appointment or continuing treatment. She will do her best to notify me.
I understand there are limits to Vicki’s expertise. She does not do custody evaluations, divorce evaluations, and she does not testify in court or do any other procedures she does not feel she is qualified to complete. I am only paying for the time I talk in the counseling conversation.
I understand that strong precautions for Privacy will be taken at the location of the counselor. No other privacy claims will be made because they are not within the scope of control for this business. Example: a customer may have their conversation in a public place.
I understand that the setting up of appointments is through a computer and the conversations are by phone so if there is a break down in technology, the appointment may not happen. Counseling conversations will do their best to reschedule if this happens.
I understand that I am responsible for all fees and that payment is due at the time of service.
I understand that once I prepay for the appointment, the money may not be refunded.