Shannon Schiefer MA, LPC 4525 S. Lakeshore Dr. Suite 102 Tempe, AZ 85282 (480) 331-4439

Informed Consent for Assessment and Treatment

Welcome to my counseling practice. I am committed to getting you whatever your outcome is for our time together. A counseling situation offers a unique relationship between the two of us. In order that we start our relationship in a healthy way, I have put together this document to ensure that there are no misunderstandings about the various aspects of the counseling and psychotherapy services.

Part I: Your Rights as Client(s)

Your counseling will begin with one or more sessions devoted to an initial assessment so that I can get a good understanding of the issues, your background, and any other factors that may be relevant. When the initial assessment process is complete, we will discuss ways to treat the problem(s) that have brought you into counseling and develop a treatment plan. You have the right and the obligation to participate in treatment decisions and in the development and periodic review and revision of your treatment plan. You also have the right to refuse any recommended treatment or to withdraw consent to treat and to be advised of the consequences or such refusal or withdrawal.

Records and Your Right to Review: Both the law and the standards of my profession require I keep clinical records for seven years. You have the right to review your records at any time except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful to you. In the case of couple’s therapy, I will release records only with the signed authorizations from all involved in treatment.

You have the right to ask questions about any procedures used during therapy. If you wish I will explain my approach and methods to you. If I see a child under the age of consent, all custodial parents have a right to the information shared in the session. Custodial parents should be aware that exercising this right may be detrimental to the therapeutic process and the therapeutic relationship, and so may wish to allow confidentiality between the child and the therapist.

Please note that I do not fill out paperwork for other organizations. This includes FLMA, disability paperwork, or any paperwork required by the courts unless required (see provisions on confidentiality).

You have the right to decide not to receive therapeutic services from me. If you wish, I will provide you with the names of other professionals whose services you might prefer to my own. You also have Shannon Schiefer, MA, LPC LPC - 12136 the right to end therapy at any time without any moral, legal or financial obligations other than those already accrued.

One of the most important rights involves confidentiality. Information revealed by you during therapy sessions will be kept strictly confidential, within the limits of the law. In order to reveal any information disclosed in sessions, to another person or agency, I will need a signed release of information authorizing this. Please also note that when more than one family member is being seen, I will view the family as a whole as the client. Therefore, releases of information for the family sessions require the written consent of each family member that was present at any time during the course of treatment.

There are certain situations where I may be required by law to reveal information obtained during therapy to other persons or agencies without your permission. Also, I am not required to inform you of any actions in this regard. The most common of these exceptions are when there is a real or potential life or death emergency, when the court issues a subpoena (signed by a judge), if you are ordered to counseling by a court of law or when child or vulnerable adult abuse or neglect is involved.

Litigation Limitation: The nature of our work together involves confidential and sensitive matters. You agree that should there be legal proceedings such as, but not limited to divorce, custody disputes, injuries, lawsuits etc, neither you nor your attorneys nor anyone else acting on your behalf will call me to testify in court or at any other proceeding or request records.

I also participate in a process where selected cases are discussed with other professional colleagues to facilitate my continued professional growth and to get you the benefit of a variety of professional experts. While no identifying information is released in this peer consultation process, the dynamics of the problems and the people are discussed along with the treatment approaches and methods.

If participating in group therapy, be aware that your therapist (s) cannot guarantee that other group members will maintain your confidentiality. However, your therapist (s) will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. Your therapist (s) also has the right to remove any group member from the group should she discover that a group member has violated the confidentiality rule.

If you are seeking payment through an insurance company, I will be required to reveal confidential information, such as diagnosis, to them. Each insurance company is different in their requirements for reimbursement.

There are also numerous other circumstances when information may be released including when disclosure is required by the Arizona Board of Behavioral Health Examiners, when a lawsuit is filed against me, to comply with worker compensation laws, to comply with the USA Patriot Act and to comply with other federal, state or local laws. The rules and laws regarding confidentiality, privacy, Shannon Schiefer, MA, LPC LPC - 12136 and records are complex. The HIPAA NOTICE OF PRIVACY PRACTICES, included in this packet of information, details the considerations regarding confidentiality, privacy, and your records. Periodically, the HIPAA NOTICE OF PRIVACY PRACTICES may be revised. Any changes to these privacy practices will be posted in my office, but you will not receive an individual notification of the updates.

I have read the HIPAA NOTICE OF PRIVACY PRACTICES, and have had my questions about privacy and confidentiality answered to my satisfaction. I understand that the HIPAA _____ NOTICE OF PRIVACY PRACTICES is incorporated by Initials reference into this agreement.

You have the right to know about the possible harmful results of therapy. One possible harm I have witnessed has resulted from client’s use of medical insurance for psychotherapy and court involvement. Harmful events included: denial of insurability when applying for medical and disability insurance due to DSM-IV-TR diagnosis (mental illness diagnosis, which are usually required for reimbursements under medical insurances); company (mis)control of information when claims are processed; loss of confidentiality due to the large number of persons handling claims; loss of employment, and repercussions of diagnosis in situations which require truthfulness about “mental illness”, including driver licenses applications, concealed weapons permits, and job applications and disclosure/(mis)interpretation of information indicating a particular court ruling.

In the event of my death or incapacity, the records for my clients that are actively receiving services (seen within the last month) will be given to one or more local behavioral health professionals to facilitate the continuation of treatment. In such a situation, you have the right to continue treatment with this professional, discontinue treatment, or ask for a referral. Records for my inactive clients will be handled by a “records custodian,” which may be an individual or company. The custodian will be responsible for satisfying records requests and destroying records when the legal timeframes for records retention are satisfied. If my practice is sold or terminated, please check my website, www.shineoncounseling.com for updated information on how to access your records. In accordance with HB-2786 Addendum #3, this is to serve as a written protocol for secure storage, transfer and access to client records. ● All clients will be notified in writing before terminating the practice ● Clients will receive a contact number and procedure for accessing their records ● All records will be secured in a secured storage area ● Therapist will respond within 2 weeks for request for copies of or access to their records ● All unclaimed records will be destroyed after a specific period of time

Social Media and Internet Search policy: I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social Shannon Schiefer, MA, LPC LPC - 12136 networking web sites. Please feel free to ‘Like’ my business page Shannon Schiefer on Facebook for informative, positive and helpful articles and posts.

Part II: The Therapeutic Process

Therapy will seek to meet goals established by all persons involved, usually revolving around a specific presenting problem. Possible benefits from therapy include an improved ability to cope with marital, family or interpersonal relationships, a greater understanding of family and/or personal values and goals, and a greater level of maturity and happiness as an individual and in your relationships.

While the ultimate goal of counseling is to reduce distress through a process of personal change, there are no guarantees that the treatment provided will be effective or useful. The process also usually involves the working through of tough personal issues which may cause more distress, at least initially, for you. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that therapy will yield positive or intended results. In the case of family counseling, conflict can increase as we discuss family issues.

The client/counselor relationship is unique in that it is exclusively therapeutic. In other words, it is inappropriate for a client and a counselor to spend time together socially, to bestow gifts, or to attend family or religious functions. The purpose of these boundaries is to ensure that you and I are clear in our roles for your treatment and that your confidentiality is maintained.

If there is ever a time when you believe that you have been treated unfairly or disrespectfully, please talk with me about it. It is never my intention to cause this to happen to my clients, but sometimes misunderstandings can inadvertently result in hurt feelings. I want to address any issues that might get in the way of the therapy as soon as possible. This includes administrative or financial issues as well.

I reserve the right to refer a client to another therapist or appropriate resource at any time if their needs in therapy are not a good match for my skills or experience.

My practice does not have the capability to respond immediately to counseling emergencies. True emergencies should be directed to local emergency services (911) or to the local hotline (Maricopa County Crisis Line – 602-222-9444 or EMPACT -480-784-1500 ). I will return messages left on my voicemail however there is no guarantee that my response will be immediate, so if you feel that your need is an emergency, please use the numbers listed above.

Part III: Fees and Length of Therapy

∙ I agree to enter into therapy with Shannon Schiefer, MA, LPC. I agree to pay ______for each session.

Shannon Schiefer, MA, LPC LPC - 12136 ∙ Payment is due at the end of each 50-60 minute session, and no balance will be carried.

∙ I charge $120 per hour for other professional services you may need including: report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service that you may request of me. If you become involved in legal proceedings that require my participation (see provisions for serving as a treating clinician), you will be expected to pay for my professional time, including preparation and transportation costs. Because of the complexity of legal involvement, I charge $325 per hour with a four-hour minimum requirement for preparation, travel time and attendance at any legal proceeding. In addition this fee will need to be paid in advance.

∙ If you would like to schedule more than 60 minutes, I can offer 75 and 90 minute sessions. The session rate would be pro-rated based on my hourly rate. In order for me to make the appropriate adjustments in my schedule, please let me know in advance if you want to schedule more time. (Insurance typically does not pay for sessions longer than 60 minutes. You would be responsible for the price difference at the time of the session)

∙ Co-payment is due at the end of each session. I am responsible for cooperating with my insurance company to support prompt payment.

∙ I understand that I can leave therapy at any time and that I have no moral, legal or financial obligation other than those already accrued.

∙ If you do not schedule an appointment within a 3 month period and choose to return to my counseling practice, you would be considered a new client and may need to complete a new assessment.

∙ I reserve the right to set and change my schedule as needed. I will give you notice, if any changes are made. I will do my best to meet your scheduling needs. If I am unable to do so, I will provide appropriate referrals and help coordinate transfer in services in a timely manner

∙ Regular attendance at my scheduled appointments is one of the keys to a successful outcome in counseling. A 24-hour notice is required for cancellation of a scheduled session. If I do not meet this requirement, I agree to pay $75.00 for late cancellations and/or no shows. I understand that this is my responsibility, not that of the third-party payer. Repeated late cancellations or missed appointments will be billed at the full fee and may result in termination of treatment. Also, if you arrive more than 15 minutes late for an appointment, I cannot bill the insurance company for a full session, therefore you will be expected to make up the difference. There is a $35.00 fee for all returned checks.

∙ I understand that I am responsible for payment in full. I will be supplied with a superbill that can be turned into my insurance company for reimbursement. However, payment for services is ultimately my responsibility, not the responsibility of the insurance company. Shannon Schiefer, MA, LPC LPC - 12136 ∙ I understand that the therapist has the right to seek legal recourse to recoup any unpaid balance. In pursuing these measures, the therapist will only disclose biographical information and the amount owed, in order to ensure confidentiality. The therapist reserves the right to change fees with 30 days notice and to use the services of a third-party collections service, when necessary. Refunds are not made after the services have been rendered.

I hereby give consent for evaluation and treatment under the terms described in this consent document and the HIPAA NOTICE OF PRIVACY PRACTICES. I acknowledge that I have received a copy of this informed consent agreement and the HIPAA NOTICE OF PRIVACY PRACTICES. In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardian of the child and that I authorize services for the child under the terms of this agreement.

Client Signature: ______Date: ______

Client Signature: ______Date: ______In the case of a minor child, please specify the following:

Full name of minor :______DOB:______Relationship: ______

Therapist Signature: ______Date: ______

Shannon Schiefer, MA, LPC LPC - 12136