Tara C. Gutgesell, MA, LPC LLC

Tara C. Gutgesell, MA, LPC LLC 1407 Bethlehem Pike, 2 nd FL, Flourtown, PA 19031 t-215-836-1934 f-215-836-1969 tcgcounselingpa@gmail.com Practice Information and Consent for Counseling Welcome and thank you for choosing professional counseling services with my practice. I look forward to providing you with professional and competent; personally, tailored counseling. This document will provide you with information you will need to make an informed decision about counseling services and the policies employed by this practice. We will review this agreement together to give you an opportunity to ask any questions you might have. Counseling Process Counseling can be a powerful tool to evoke change in thoughts, action, behavior and health. Techniques employed in your counseling are specifically identified based on the information communicated and collected during our sessions. By entering into counseling, you agree to work together to evaluate your counseling needs and to engage in the process willingly. Counseling can include exploring different areas of your life including social, emotional, biological, developmental, and environmental factors which contribute to your current, past, and future circumstances. Sometimes this process is relatively short, while other times it may take a longer sequence of services to fully meet the goals of counseling. This process will also require you to practice and work on your goals of therapy in and outside of our sessions. There are benefits, and risks associated with counseling. There is no guarantee to know how it will impact you as it affects people in various ways. During the counseling process, exploration of treatment goals may bring up uncomfortable feelings and difficult areas to address. You have full control of what you communicate and when. It is important that you feel comfortable and safe in what you decide and when you decide what you would like to address. In many cases clients will feel relief just by talking in sessions. However, sometimes clients may feel an increase in symptoms as more difficult life circumstances are addressed. Sticking through this process, most clients experience the benefits of counseling. Benefits of counseling can include improving daily functioning emotionally, physically, and socially. Please feel free to discuss further with me how counseling may impact you. Sessions, Professional Services, and Fees Intake sessions will last 60 minutes. After our intake session and treatment planning sessions (2-3 sessions, 45-50 minutes), together we will decide whether I am the best person to provide the services you need to meet your treatment goals. If we decide to continue with counseling, we will schedule forty-five to fifty-minute sessions at mutually agreed upon times (usually weekly). Generally counseling is short term, lasting 10-12 sessions or longer depending on need; and number/complexity of treatment goals. If during the process of treatment either one of us decide that the counseling services are not effective or if your need in counseling is beyond the scope of my practice, an appropriate referral will be provided for you. TG 07/2017 Initials Page 1

Intake session are $130. Individual Sessions (45-50 minutes) are $100. In addition to therapy appointments, I charge $100/hour on a prorated basis for other professional services you may need. Other professional services may include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing other services you may request. Please note that these additional services are not covered by insurance companies, and you will be responsible for these fees. Sessions will begin and end as promptly as possible. If you are later than 15 minutes for your session, your session will need to be rescheduled; and you will be required to pay the late cancellation fee. Once an appointment is scheduled, you will be expected to pay for the session unless you provide 24 hours advanced notice of cancellation. Payment in the form of cash, check or credit card is expected at the start of each session. There is a $50 service charge for any returned check. I request to keep a credit card of your choice on file if you cancel under 24 hour notice or if you forget to bring payment at the time of session to properly bill you. (Please refer to credit card consent form.) If possible, the missed appointment can be rescheduled by contacting me as soon as possible. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If you are in the midst of any type of legal issues such as litigation, a dispute with employer, separation or divorce, please inform me immediately. It is important that you understand your rights and limitations should records or information be requested regarding your counseling services. If there is a request for any court proceedings on my behalf, fees will be established to adequately cover the time and effort required to fulfill court orders; and is substantial in matter. Insurance companies will not cover these expenses and you will be responsible for any fees incurred in these rare circumstances. Please also note that I do not make recommendations related to court processes or requests. I can refer you to professionals who can provide court evaluations. I also do not make recommendations related to legal matters to probation officers or requests for gun permits. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim]. Insurance Reimbursement There are benefits and limitations to consider when using insurance coverage to pay for your services. Please check with your insurance company to determine your coverage and eligibility of your benefits with my practice. Using insurance requires that I submit confidential information to your insurance company to approve necessary coverage, including but not limited to a diagnosis. Some people choose not to utilize insurance for this very reason of privacy. However, only the minimal amount of information necessary to approve the use of benefits is provided. At times insurance companies choose to audit information. By using insurance, you are granting this practice permission to communicate confidential information to your insurance. You are responsible for session payment including co-pay should your insurance company deny requests for payment. If you choose to use insurance, it is important for you to notify the practice of any changes to policy, copay, or providers as soon as that information is made available to you. TG 07/2017 Initials Page 2

If this practice is out of network with your insurance, you may submit requests for reimbursement from your insurance via a bill receipt provided by this practice. Please check with your insurance company about out of network benefits prior to doing so to ensure reimbursement. Communication & Office Hours The practice hours vary. Your communication with me is very important. Phone contacts are welcome for scheduling, notification of change in schedule, or if a matter of emergency presents outside of session times. Please feel free to leave a brief message with the best number and available times to contact you in return. I will make my best effort to return your call during normal business days of Monday-Friday within 24 hours. This practice does not offer 24 hours a day emergency response but provides alternative resources listed here for off hour coverage. If you are experiencing an emergency that cannot wait until my return call or your next scheduled appointment, please contact Montgomery Emergency Services at 610-279-6100; Philadelphia Mental Health Delegate at 215-685-6440; National Suicide Prevention Hotline at 1-800-273-TALK ; as well as your local emergency room, or 911. If you have questions about the limitations of the practice services, please feel free to speak with me to discuss the most appropriate response plan for you. Attendance, Case Closure/Discharge from services, and Referrals It is important to keep your appointments and attend regularly to maximize benefits of counseling. If you should need to reschedule, please contact the practice as soon as possible. If you should miss appointments consecutively, without reason, we will discuss your treatment plan and preparedness for services. Additionally, if you do not show up for a scheduled appointment without contact or more than 15 minutes late, outreach will be made to you at your preferred method of contact to inquire about the missed appointment. If there is no contact with the practice after 45 days, without expression to continue services or communication from you, your case may be closed at that time. Please note in most cases this is an administrative function and does not necessarily preclude you from seeking services again in the future. Your treatment goals, attendance, and progress are our gauge to knowing when ending services is appropriate. We will continue to evaluate this throughout your services, collaborating with one another regarding your needs. Your communication regarding how you are feeling and experiencing services is key to helping us to measure progress and completion of services. Referrals can be made at discharge when necessary if alternative services are needed; or if you request a referral. Code of Ethics Our work together is guided and governed by the American Counseling Association s code of ethics. A copy of this is available online or upon request. As such, it is helpful for me to indicate some information about our professional relationship. Counselors are obligated to maintain appropriate boundaries with current and former clients. Our interactions are limited to the professional context of your counseling sessions. Therefore, invitations to social engagements or events are prohibited, as are gifts; and requests to join social media, or networking groups. Communication via email are restricted to scheduling of appointments or appointment changes. Should we encounter one another outside of the counseling office, it is at your discretion to acknowledge our professional relationship. Out of TG 07/2017 Initials Page 3

respect of your privacy and confidentiality, I will not initiate any acknowledgement. These are examples of but not limited to some the professional obligations I am under to protect your best interests. You are encouraged to discuss with me any concerns regarding treatment protocols, satisfaction of your services, or complaints. Your feedback and opinion regarding your care are my priority. Should you feel that I have not ethically or adequately addressed a complaint you can contact the state licensing board. Confidentiality, Communication, and Records Release Confidentiality is guided by Pennsylvania/Federal laws, including HIPAA and professional ethics. Communications between a counselor and client are confidential an are not disclosed without your written consent. There are some exceptions to your privilege of confidentiality. Please review the HIPAA Notice of Privacy Practices for further information. Below are the circumstances where confidentiality cannot be maintained. 1. If it is necessary to protect you or someone else from danger, including imminent risk of suicide or homicide, I may be required to access hospitalization or contact an emergency contact on your behalf to ensure protection. Please communicate with me any plans you have for suicide or homicide. If you are unable to reach me, you are to contact 911 or the crisis numbers listed above. Please initial here that you agree to inform me of changes in your ability to maintain safety and understand this information. 2. I am a mandated reported. By law if there is suspected abuse (sexual, physical, emotional) or neglect of a child (anyone under the age of 18) or an incapacitated adult has occurred I am bound by law to report it to authorities. 3. In rare instances when a court of law subpoenas release records (in which case I will attempt to contact you). In the event this occurs you are encouraged to discuss this with your attorney to explore options that may be taken for your protection. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. 4. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this consent. 5. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding treatment to defend myself 6. If you decide to sign an Authorization of Release of Records form, granting permission to release/obtain records to you or another party. If the situation arises in which release of records is necessary, it is important for you to discuss the implications of such a release with me. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. Rights of Consultation/Recording of sessions Peer supervision or consult with another professional licensed in the mental health field, or the licensing board may be necessary from time to time to provide the highest quality of care for you. Identifying information is not shared during consultation/supervision. TG 07/2017 Initials Page 4

I do not record sessions for clinical purposes. Should you feel the need to record any portion of a session for any reason, please discuss this in advance with me. You are encouraged to make notes for yourself during sessions to help with recall of themes discussed, suggestions for homework, or ideas related to your treatment goals. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information such as: (1) This agreement; (2) Client Intake Form; (3) any emails we exchange; (4) any assessment materials that I may use during the course of our work together; and (5) and any other medical records or doctor s notes/letters pertaining to you. Your clinical records include information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. These records may be kept electronically. Except in unusual circumstances that involve danger or substantial harm to yourself or others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to non-mental health professionals. For this reason, I recommend that you initially review records in my presence. Consent for Services and Acknowledgement of Practice Information While I expect benefits from this treatment I fully understand and accept that because of factors beyond control, such benefits and desired outcomes cannot be guaranteed. I understand that the therapist is not providing emergency services and I have been informed to call Montgomery Emergency Services, Philadelphia s mental health delegates, a crisis intervention hotline, or 911 in an emergency or during evening, weekend, or holiday hours. I am not aware of any reason why I should not proceed with counseling and agree to participate fully and voluntarily. I am free to discontinue treatment at any time in accordance with this agreement. I have had the opportunity to discuss all aspects of treatment fully, have had my questions answered, and understand the information indicated. I authorize Tara C. Gutgesell, MA, LPC to provide treatment. Name: Date: Witness: Date: Signing this agreement indicates that you understand/accept the information and policies; and agree to the implementation of the polices. You have the right to revoke this agreement at any time, in writing. However, understanding that revocation will be binding on me unless I have taken action in reliance on it, if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied any financial obligations you have incurred. TG 07/2017 Initials Page 5