<p> Dillon International Post Adoption Services: Information and Policy Statement for Counseling</p><p>Please read the following important information. If you have any questions, you may discuss them with your counselor.</p><p>Confidentiality: Federal HIPAA and state laws require that what you say in a counseling relationship is protected by law. The legal exceptions to confidentiality include (1) revealing intent to harm yourself or someone else, (2) suspected child or elder abuse or neglect and (3) instances where the court or government subpoena records. It is impossible to protect the confidentiality of information that is submitted electronically.</p><p>The Therapeutic Process, Benefits and Risks: We endeavor to work together to reach personal goals, attain resolution of conflicts, relieve symptoms, resolve past wounds and achieve personal growth. This may include evaluations, psychotherapy, counseling and other modes of treatment tailored to your needs. In the pursuit of these changes, there may be times of unpleasant emotions and disruptions in other areas of life. This is a normal part of change and you should be aware of these risks before you begin counseling. We do not use email exchanges as a part of counseling. At any time you have a right to an explanation of the counseling plan and at any time you may decline treatment.</p><p>Length of Treatment: Counseling will end when you and your counselor decide that your personal goals have been reached. You have the right to end or take a break from counseling at any time.</p><p>Appointments: Appointments are scheduled weekly or every other week. The standard practice is to set up your next appointment during each appointment. Appointments are one hour in length.</p><p>Cancellations: If you need to cancel an appointment, 24 hour notice is required.</p><p>Fees: The current fee is $100.00 an hour. All fees must be paid prior to the session. There will be a $20.00 charge for each “non-sufficient funds” check return. If a payment plan is agreed upon, the maximum account balance permitted is $300.00. The maximum account balance permitted is $300.00. Once this balance is reached, counseling may be discontinued until further payment is received. Professional time spent outside of the telephone consultation, including, but not limited to between-session phone calls or email exchanges, report writing and reading or reviewing documents, will be billed on a prorated basis rounded up to the nearest tenth of an hour. If we are required to attend meetings outside of our offices, you will also pay for traveling time and mileage.</p><p>Emergencies and After Hour Care: Our general philosophy is that clients are assumed to be self -responsible for emergencies by calling 911 or going to the emergency room. We do not provide crisis or emergency services. You may leave a voice mail message during the week. If you need recurring phone contact as a regular addition to your therapy, the fee is $10.00 per 5-minute period.</p><p>Your signature indicates you have read the information, you will abide by the terms of our professional relationship and you have been provided the HIPAA Notice of Privacy Practices.</p><p>Date </p><p>Client/Guardian Signature </p><p>Client/Guardian Name (print) </p>