Dr. Carol A. Houston

Dr. Carol A. Houston Licensed Psychologist 5926 S. Staples, D-9 Phone: (361) 816-3638 Corpus Christi, Texas 78413 Fax: (361) 992-6835

Consent for Treatment Client: ______Date of Birth: ______Parent/Guardian: ______Relationship: ______

This form is to document that I give my permission and consent to Dr. Carol A. Houston, to provide psychotherapeutic treatment to me and/or my child. Dr. Houston offers individual therapy, marital therapy, family therapy, relationship therapy, stress management, substance abuse counseling, and weight management. Dr. Houston utilizes a variety of therapeutic methods and techniques, including reality therapy, grief therapy, cognitive behavioral therapy and life skills development such as communication skills, stress management skills, problem solving skills, and interpersonal skills.

Dr. Houston will work with me to establish appropriate therapeutic goals of therapy (such as symptom reduction, improved communication, etc.) as well as procedures to be utilized (such as stress management training, cognitive techniques, etc.). Goals may change as therapy progresses, and my input is very important in establishing appropriate therapeutic goals. While it is sometimes difficult to anticipate how much therapy may be needed to resolve the presenting problems and achieve satisfactory progress towards the therapeutic goals, Dr. Houston will estimate the anticipated duration of treatment. The recommended frequency of treatment will also be discussed (generally weekly or every other week, but sometimes twice/week for more severe problems). While I expect benefits from this treatment, I fully understand that because of factors beyond Dr. Houston’s control or other factors, such benefits and particular outcomes cannot be guaranteed. I understand that as a result of counseling or therapy I may experience emotional strains, feel worse during treatment, and make life changes which could be distressing.

I understand that in the event of an emergency, I am to call (361) 816-3628. If I am unable to reach Dr. Houston, I can leave a message and someone will return my call. If I am unable to reach someone, I understand that I need to seek medical attention. I am to call my healthcare provider, go to the nearest emergency room, or call 911 if it is a life-threatening event for me or others.

I understand that regular attendance will produce the maximum effects, but that I am free to discontinue treatment at any time. If I decide to do so, Dr. Houston requests that I notify her at least two weeks in advance so that effective planning for continued care can be implemented.

I understand that conversations with Dr. Houston will almost always be confidential. I further understand that Dr. Houston, by law, must report actual or suspected child or elder physical or sexual abuse to the appropriate authorities. In addition, Dr. Houston has a legal responsibility to protect anyone a client may threaten with violence, harmful or dangerous actions (including those to me) and may break confidentiality of our communications if such a situation arises. I understand that Dr. Houston will make reasonable efforts to resolve these situations before breaking confidentiality. In addition, I understand that Dr. Houston may sometimes consult about my treatment with other professionals, who are also legally bound to maintain my confidentiality. My name will not be used in such circumstances. Similarly, if Dr. Houston is out of town or unavailable, another Page 1 professional will be on call for her, and some information may be provided to that person. With my written permission, Dr. Houston’s records may be released to another professional or agency. Records may also be released in judicial proceedings as specified by law.

I understand that I am financially responsible for this treatment. I understand the first evaluation session is $200 and subsequent visits are $100 with payment due at time of service, unless Dr. Houston agrees to other billing arrangements. If I am covered by a managed care plan for which Dr. Houston is a participating provider, the rate I am responsible for will be determined by Dr. Houston’s contract with the managed care plan. Generally, Dr. Houston will file insurance claims, and I am responsible for the deductible, co-insurance, and co pay amounts. Services provided under Workers Compensation will be reimbursed solely by Workers Compensation. In the case of Tricare, Medicare and Medicaid, the allowable rates are established by the state of Texas or by the federal government. There are other public sources of help available in the community including focused self-help groups such as AA, NA, etc. It is possible that therapeutic services may also be available without charge from an Employee Assistance Program or from the local school district.

The regular fee (or the allowable charge under managed care) will be billed directly to me for any missed appointments that I have not cancelled at least 24 hours in advance. Dr. Houston may make an exception in the event of an emergency. Overdue accounts may be referred to a collection agency, and Dr. Houston will notify me in advance in order to give me an opportunity to take care of an overdue balance prior to the account being turned over to a collection agency.

Dual relationships such as social relationship or business relationship are unethical and are not a part of Dr. Houston’s practice.

I understand that my records will be destroyed in ten years after my last session. In the case of a minor, records will be destroyed ten years after the last session or when the minor turns 28, whichever is greater.

I know of no reason why I should not undertake this therapy and I agree to participate fully and voluntarily.

Dr. Houston is a licensed psychologist, certified reality therapist, certified grief therapist and certified resolution anger therapist in the State of Texas. She received her M.S. in Counseling at Corpus Christi State University (Texas A&M University – Corpus Christi) in 1974 and her doctorate from the University of Houston in 1982. She has additional training in addictions, weight management, and grief therapy.

I agree to inform Dr. Houston if I have any concerns that arise during the course of treatment regarding my therapy or the fees for my therapy, and Dr. Houston will work with me to attempt to resolve these concerns.

Consumer Complaint Hotline – 1-800-942-5540

______Signature of client or person authorized to consent for client Date