counseling services welcome packet · 2016-12-31 · counseling services individual therapy spirit...

CounselingServicesIndividualTherapySpiritJourneyLLC

Unfold Purpose. Embrace the Now. Ignite Plans & Passions.

Welcome Packet

Take a deep breath….you have made a good decision. It is hard to take the step in finding help for the things we struggle with, even harder to decide who to work with and who to trust. You may have talked yourself out of contacting someone or me several times before you actually did. That’s normal…very normal. You are worth the time and this will be worth it in the end. Thank you for entrusting your time with me. I can’t tell you to trust me, as trust must be felt and earned. I can share with you that I am dedicated to your wellbeing and in identifying the path to get you to your best you! I have been journeying with people for over 18 years, and I look forward to our time together. This packet may seem a bit overwhelming, as there are several things that I want to cover with you. Take time to read through everything and complete the pages where needed, but do so how you need to. If there are any questions, please contact me at #480-241-8678.

The Process: I honor your time, so I begin my appointments on time. Each session together will last 50 minutes, allowing you the necessary time to share and for us to work collaboratively toward your goals. Prior to our first session together, you will have forms on confidentiality and informed consent, along with an intake form, which will provide me historical information about you. I encourage you to complete these prior to our first session and send them to me at [email protected]. This helps avoid us using valuable time in our first session on this task. Our first session together will include things such as identifying your therapeutic goals and discussion on current barriers and successes being experienced. While I realize that it is hard to immediately share private matters with a complete stranger, I encourage you to take the time necessary to feel safe and comfortable in sharing with me but to also come to each session prepared to engage in this work together. I encourage you to let me know what you want to work on at each session, as this is your journey.

Counseling Sessions: Our time together will be completed face-to-face in the office and the frequency of sessions will be driven by your counseling needs. Many people want to know, “how long will I need to be in counseling?” This question is generally difficult to answer, as each person and life circumstances encountered impact the work that we do. I like to share with clients and family members that counseling is not a sprint to the end, but certainly not a long arduous marathon either. I tell most people that if you want to see sustainable results, plan on committing at least 3 months of time together. Again, people are different, so their counseling journeys will be different. Our work is very intentional and designed to get you the results you desire.

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Helping make intentional choices on your journey so you can engage in life with purpose and direction

SpiritJourneyLLCKristiStuckwisch,LCSWLISAC3200N.Dobson,Bldg.CChandler,AZ85224Ph.#480-241-8678

Typically, our work is done on a bi-weekly basis; however, some clients require more frequency while others desire less frequency. Frequency of sessions will be a part of our conversation at the initial session. Our time in session will last approximately 50 minutes. Some weeks you may have proposed growth opportunities to consider doing during our time apart from each other. Please know that everything discussed is optional, but will be intentionally designed for the sole purpose of your personal growth in achieving your goals.

If some weeks you desire a longer session time because things have occurred and you know you will require more time, please notify me at least 3 days prior to your session so we can discuss the possibility of this request. I will encourage you to schedule your follow-up appointment at the end of each session, prior to leaving the office, in order to secure your desired date and time for the next appointment. If our counseling agreement includes a pre-determined amount of sessions, the sessions can be used at your discretion.

Changes or Missed Appointments: I ask that you provide a 24 hour notice if you have to cancel or reschedule an appointment. If you have an emergency, we will work around it, but I request that 24 hours notice be provided if possible. Otherwise, a missed session or a session cancellation provided with less than 24 hours notice will be billed as if the session occurred. If our agreement includes a pre-determined amount of sessions and you or I are on vacation, then we will make up any missed session(s) either before or after the vacation. If you are over 15 minutes late for your scheduled appointment, your appointment will be cancelled and billed to you as if the session occurred. Your next session will not be booked until the payment for the missed appointment is made.

Fee: Initial consults are charged at $60 per hour. For follow up appointments, our time together is charged by the session. Single session rates are $60 per 55 minutes of counseling time. Clients must pay at the time service is rendered, unless prior arrangements have been made. Clients may pay in advance, if desired. Payments may be made with Cash, Money Order, Master Card, or Visa. If paying by credit card, I use an electronic application that sends an immediate invoice via text or email, allowing secure payment through your phone or computer.

If there is a struggle in accomplishing your session payment, please discuss this with me prior to our time together, so that we can work out a plan. Please don’t be too proud or embarrassed if this should occur, simply let me know so that we can discuss available options!

I do offer session packages at a reduced per-session rate. These packaged session deals must be pre-paid in full prior to scheduling them for use. Failure to pay in full renders each session used at the regular per session rate of $60 per 50 minutes, rather than at the reduced session rates listed below. The counseling packages available are as follows:

5 sessions for $275 ($55 per 50 minutes) 8 sessions for $400 ($50 per 50 minutes) 10 sessions for $450 ($45 per 50 minutes)

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Again, payments may be made with Cash, Money Order, Master Card, Visa or PayPal. An invoice will be provided, indicating the number of sessions purchased and the cost per session. Prior to the use of the last session in any pre-paid package deal, notification will be made and an option to purchase another package of sessions will be offered. It always remains an option for each client to return to single session payments once their packaged sessions are used. If returning to single sessions, please understand that the rate returns to the single session rate of $60 per 50 minutes of counseling.

Problems: I want you to be satisfied with our time together. If I ever say or do something that upsets you or doesn’t feel right, please bring it to my attention. I promise to do what is necessary to satisfy your counseling needs.

The Basics of Counseling with Kristi @ Spirit Journey LLC

1 All sessions begin on time. If you arrive later than 15 minutes after the scheduled time and no prior notice was provided about being late, the session will not occur and it will be billed to you for payment.

2 If it becomes necessary to reschedule or cancel an appointment, please give at least a 24-hour notice. 3 Services are paid for in advance or at the beginning of each session. MC, Visa, Cash, Money Orders are

accepted. 4 As a client, you understand and agree that you are fully responsible for your well-being during counseling

sessions, including your choices and decisions. You are aware that you can choose to discontinue counseling at any time.

5 You understand that counseling is a professional relationship with Kristi that is designed to facilitate the creation and development of personal, relational, health, and/or spiritual goals and to develop and carry out a strategy and plan for achieving those goals.

6 You understand that counseling is a comprehensive process that may involve all areas of your life including historical experiences, thoughts, emotions, faith, finances, health, relationships, education, recreation and major life transitions. You acknowledge that deciding how to handle these issues and how to implement your choices is exclusively your responsibility.

7 You understand that the professional counseling You are choosing to embark upon with Kristi includes work towards the treatment of any mental health issues that may be present in your life, as defined by the American Psychiatric Association. You understand that this treatment will be at your informed consent and that you can terminate these services at any point at your discretion.

8 You understand that Kristi is a mandatory reporter that requires her to disclose certain information shared with her. However, you also understand that outside of the mandated reporting requirements that Kristi will cover with you at the first session, that all other information shared with Kristi will be held as confidential, unless you provide written notification of consent for release of information.

9 You understand that while in counseling with Kristi, all decisions you make are exclusively yours and your actions are your responsibility.

I have read and agreed to the above.

Client Signature: ______________________________________________

Date: _______________________________________________________

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COUNSELING SERVICE FEE AGREEMENT

Please review, adjust, sign where indicated, and return to Kristi @ Spirit Journey LLC by mail or email before your first appointment. *Please contact me if we need to discuss fees

Name______________________________________________________ Address____________________________________________________ Email______________________________________________________ Phone_____________________________________________________

Spirit Journey LLC Rates: $60 for 1 50 minute session (circle your preference) $275 for 5 50 min. sessions $400 for 8 50 min. sessions $450 for 10 50 min. sessions

Preferred payment method: _____ Cash _____ Credit Card

I,________________________________agreetopayforpsychotherapyservicesandotherclinicalservicesforKristi

Stuckwisch,LCSWLISAC,accordingtothefeeagreement.Iunderstandthefollowingtermsapplytothis

agreement:Paymentwillbemadeatthetimeofservice

- Thefeeforpsychotherapy,consultation,letterorreportwritingorotherclinicalservicesis$60per50minutesession,orasagreedupon.

- PleaseinformKristiassoonasyouknowiftherearechangesinyourabilityorwillingnesstopay.

- Serviceswillbeterminatediftimelypaymentisnotmadeasagreedtobythisconsent.

- Consenttoassumefinancialresponsibilityfortheseservicesdoesnotentitlethethird-partypayeraccesstoconfidentialinformationunlessotherwiseagreedinwritingbytheabovenamedclient.

- Thisagreementsupplementspreviousinformedconsents.

SignatureofClient:______________________________________________________________Date:___________________________

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CLIENT INFORMATION

Date: Name______________________________________________________________________

Occupation:_____________________________________________________________________

Home Address:___________________________________________________________________

Day Phone:____________________________ Evening Phone:__________________________

Cell: ___________________________ Email: _________________________________________

Okay to leave message everywhere? ____________ If not, where do you prefer? ____________

Preferred means of communication:_________________________________________________

Date of birth: ________________________________ Age:_________________________

Names of important people in your life (spouse, partner, children, friends, etc.): ________________________________________________________________________________ ________________________________________________________________________________

Emergency contact name and phone number: ________________________________________________________________________________

Problems Facing in Life (be as specific as you can: when did this start, how does it affect you) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

How Much does this Impact Your Ability to Function: ___Mild ___Moderate ___Severe __Very Severe

If you don't address this now, what do you foresee happening?

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CLIENT INFORMATION - 2

PAST/PRESENTDRUG/ALCOHOLUSE/ABUSE(what,howmuch,forhowlong,anyrehab):

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Have you ever done counseling before ? _____________

If yes, who was your provider? ____________________________________________________________

How long did you work with this provider? ___________ Mo / Yr

What successes/progress did you make?_______________________________________________________

Currently Taking Medications? Yes / No If so, what?_____________________________________

Why do you want to come to counseling now? __________________________________________________

Any legal issues? Yes / No If so, what?_____________________________________________________

Where do you want to focus first? _________________________________________________________________________________________

What parts of your life are working best now? _________________________________________________________________________________________

GOALS What goals do you want to accomplish? And by when?

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INFORMEDCONSENT

PSYCHOTHERAPY INFORMATION DISCLOSURE STATEMENT

Therapyisarelationshipthatworksinpartbecauseofclearlydefinedrightsandresponsibilitiesheldbyeachperson.Thisframehelpstocreatethesafetytotakerisksandthesupporttobecomeempoweredtochange.Asaclientinpsychotherapy,youhavecertainrightsthatareimportantforyoutoknowaboutbecausethisisyourtherapy,whosegoalisyourwell-being.Therearealsocertainlimitationstothoserightsthatyoushouldbeawareof.Asatherapist,Ihavecorrespondingresponsibilitiestoyou.

My Responsibilities to You as Your Therapist

I. Confidentiality

Withtheexceptionofcertainspecificexceptionsdescribedbelow,youhavetheabsoluterighttotheconfidentialityofyourtherapy.Icannotandwillnottellanyoneelsewhatyouhavetoldme,oreventhatyouareintherapywithmewithoutyourpriorwrittenpermission.UndertheprovisionsoftheHealthCareInformationActof1992,Imaylegallyspeaktoanotherhealthcareprovideroramemberofyourfamilyaboutyouwithoutyourpriorconsent,butIwillnotdosounlessthesituationisanemergency.Iwillalwaysactsoastoprotectyourprivacyevenifyoudoreleasemeinwritingtoshareinformationaboutyou.Youmaydirectmetoshareinformationwithwhomeveryouchose,andyoucanchangeyourmindandrevokethatpermissionatanytime.Youmayrequestanyoneyouwishtoattendatherapysessionwithyou.

YouarealsoprotectedundertheprovisionsoftheFederalHealthInsurancePortabilityandAccountabilityAct(HIPAA).Thislawinsurestheconfidentialityofallelectronictransmissionofinformationaboutyou.WheneverItransmitinformationaboutyouelectronically(forexample,sendingbillsorfaxinginformation),itwillbedonewithspecialsafeguardstoinsureconfidentiality.

Ifyouelecttocommunicatewithmebyemailatsomepointinourworktogether,pleasebeawarethatemailisnotcompletelyconfidential.Allemailsareretainedinthelogsofyourormyinternetserviceprovider.Whileundernormalcircumstancesnoonelooksattheselogs,theyare,intheory,availabletobereadbythesystemadministrator(s)oftheinternetserviceprovider.AnyemailIreceivefromyou,andanyresponsesthatIsendtoyou,willbeprintedoutandkeptinyourtreatmentrecord.

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The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.

1.IfIhavegoodreasontobelievethatyouwillharmanotherperson,Imustattempttoinformthatpersonandwarnthemofyourintentions.Imustalsocontactthepoliceandaskthemtoprotectyourintendedvictim.

2.IfIhavegoodreasontobelievethatyouareabusingorneglectingachildorvulnerableadult,orifyougivemeinformationaboutsomeoneelsewhoisdoingthis,ImustinformChildProtectiveServiceswithin48hoursandAdultProtectiveServicesimmediately.Ifyouarebetweentheagesof16and18andyoutellmethatyouarehavingsexwithsomeonemorethanfiveyearsoldthanyou,orsexwithateacheroracoach,ImustalsoreportthistoCPS,eventhoughatage16youhavetherighttoconsenttosexwithsomeonenomorethanfiveyearsolderthanyou.IwouldinformyoubeforeItookthisaction.

3.IfIbelievethatyouareinimminentdangerofharmingyourself,Imaylegallybreakconfidentialityandcallthepoliceorthecountycrisisteam.Iamnotobligatedtodothis,andwouldexploreallotheroptionswithyoubeforeItookthisstep.Ifatthatpointyouwereunwillingtotakestepstoguaranteeyoursafety,Iwouldcallthecrisisteam.

4.Ifyoutellmeofthebehaviorofanothernamedhealthormentalhealthcareproviderthatinformsmethatthispersonhaseithera.engagedinsexualcontactwithapatient,includingyourselforb.isimpairedfrompracticeinsomemannerbycognitive,emotional,behavioral,orhealthproblems,thenthelawrequiresmetoreportthistotheirlicensingboard.Iwouldinformyoubeforetakingthisstep.If you are my client and a health care provider, however, your confidentiality remains protected under the law from this kind of reporting.

The next is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy with me.

Ifyouandyourpartnerdecidetohavesomeindividualsessionsaspartofthecouplestherapy,whatyousayinthoseindividualsessionswillbeconsideredtobeapartofthecouplestherapy,andcanandprobablywillbediscussedinourjointsessions.Do not tell me anything you wish kept secret from your partner. Iwillremindyouofthispolicybeforebeginningsuchindividualsessions.

II. Record-keeping.

Ikeepverybriefrecords,notingonlythatyouhavebeenhere,whatinterventionshappenedinsession,andthetopicswediscussed.IfyoupreferthatIkeepnorecords,youmustgivemeawrittenrequesttothiseffectforyourfileandIwillonlynotethatyouattendedtherapyintherecord.UndertheprovisionsoftheHealthCareInformationActof1992,youhavetherighttoacopyofyourfileatanytime..YouhavetherighttorequestthatIcorrectanyerrorsinyourfile.YouhavetherighttorequestthatImakeacopyofyourfileavailabletoanyotherhealthcareprovideratyourwrittenrequest.Imaintainyourrecordsinasecurelocationthatcannotbeaccessedbyanyoneelse.

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III. Diagnosis

Ifathirdpartysuchasaninsurancecompanyispayingforpartofyourbill,Iamnormallyrequiredtogiveadiagnosistothatthirdpartyinordertobepaid.Diagnosesaretechnicaltermsthatdescribethenatureofyourproblemsandsomethingaboutwhethertheyareshort-termorlong-termproblems.IfIdouseadiagnosis,Iwilldiscussitwithyou.AllofthediagnosescomefromabooktitledtheDSM-V; Ihaveacopyinmyofficeandwillbegladtoshowittoyou,sothatyoucanlearnmoreaboutwhatitsaysaboutyourdiagnosis.

IV. Other Rights

Youhavetherighttoaskquestionsaboutanythingthathappensintherapy.I'malwayswillingtodiscusshowandwhyI'vedecidedtodowhatI'mdoing,andtolookatalternativesthatmightworkbetter.Youcanfeelfreetoaskmetotrysomethingthatyouthinkwillbehelpful.Youcanaskmeaboutmytrainingforworkingwithyourconcerns,andcanrequestthatIreferyoutosomeoneelseifyoudecideI'mnottherighttherapistforyou.Youarefreetoleavetherapyatanytime.

My Training and Approach to Therapy

IhaveaMasterinSocialWorkearnedin1997atArizonaStateUniversity.IamanArizonaLicensedClinicalSocialWorker(#11452)andLicensedIndependentSubstanceAbuseCounselor(#10333).Myareasofspecialtrainingandexpertiseincludesubstanceusedisorders,traumaandloss,grief,stressandcompassionfatigue.

Iuseavarietyoftechniquesintherapy,tryingtofindwhatwillworkbestforyou.Thesetechniquesarelikelytoincludedialogue,interpretation,cognitivereframing,awarenessexercises,self-monitoringexperiments,visualization,journal-keepingandreadingbooks.IfIproposeaspecifictechniquethatmayhavespecialrisksattached,Iwillinformyouofthat,anddiscusswithyoutherisksandbenefitsofwhatIamsuggesting.Imaysuggestthatyouconsultwithaphysicalhealthcareproviderregardingtreatmentsuggestionsthatcouldhelpyourproblems;Irefertotraditionalandnon-traditionalpractitioners,andwillbegladtodiscusswithyoutheprosandconsofvariousalternatives.Imaysuggestthatyougetinvolvedinasupportgroupaspartofyourwork;however,againthisisasuggestion.Ifanotherhealthcarepersonisworkingwithyou,IwillneedareleaseofinformationfromyousothatIcancommunicatefreelywiththatpersonaboutyourcare.YouhavetherighttorefuseanythingthatIsuggest.Idonothavesocialorsexualrelationshipswithclientsorformerclientsbecausethatwouldnotonlybeunethicalandillegal,itwouldbeanabuseofthepowerIhaveasatherapist.

Therapyalsohaspotentialemotionalrisks.Approachingfeelingsorthoughtsthatyouhavetriednottothinkaboutforalongtimemaybepainful.Makingchangesinyourbeliefsorbehaviorscanbescary,andsometimesdisruptivetotherelationshipsyoualreadyhave.Youmayfindyourrelationshipwithmetobeasourceofstrongfeelings,someofthempainfulattimes.Itisimportantthatyouconsidercarefullywhethertheserisksareworththebenefitstoyouofchanging.Mostpeoplewhotaketheserisksfindthattherapyishelpful.

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Younormallywillbetheonewhodecidestherapywillend,withthreeexceptions.Ifwehavecontractedforaspecificshort-termpieceofwork,wewillfinishtherapyattheendofthatcontract.IfIamnotinmyjudgmentabletohelpyou,becauseofthekindofproblemyouhaveorbecausemytrainingandskillsareinmyjudgmentnotappropriate,Iwillinformyouofthisfactandreferyoutoanothertherapistwhomaymeetyourneeds.Ifyoudoviolenceto,threaten,verballyorphysically,orharassmyself,theoffice,anyofmystafformyfamily,Ireservetherighttoterminateyouunilaterallyandimmediatelyfromtreatment.IfIterminateyoufromtherapy,Iwillofferyoureferralstoothersourcesofcare,butcannotguaranteethattheywillacceptyoufortherapy.

Iamawayfromtheofficeseveraltimesintheyearforvacationsortoattendprofessionalmeetings.IfIamnottakingandrespondingtophonemessagesduringthosetimesIwillhavesomeonecovermypractice.Iwilltellyouwellinadvanceofanyanticipatedlengthyabsences,andgiveyouthenameandphonenumberofthetherapistwhowillbecoveringmypracticeduringmyabsence.Iamavailableforbriefbetween-sessionphonecallsduringnormalbusinesshours.IfyouareexperiencinganemergencywhenIamoutoftown,oroutsideofmyregularofficehours(after5pmweekdaysorovertheweekend),pleasecallthelocalCrisisLine.Ifyoubelievethatyoucannotkeepyourselfsafe,pleasecall911,orgotothenearesthospitalemergencyroomforassistance.

Your Responsibilities as a Therapy Client

Youareresponsibleforcomingtoyoursessionontimeandatthetimewehavescheduled.Sessionslastfor50-55minutes.Ifyouarelate,wewillendontimeandnotrunoverintothenextperson'ssession.Ifyoumissasessionwithoutcanceling,orcancelwithlessthantwenty-fourhoursnotice,youmustpayforthatsessionatournextregularlyscheduledmeeting.Thephonelinehasatimeanddatestampwhichwillkeeptrackofthetimethatyoucalledmetocancel.Theonlyexceptiontothisruleaboutcancellationisifyouwouldendangeryourselfbyattemptingtocomeorifyouorsomeonewhosecaregiveryouarehasfallenillsuddenly.Ifyouno-showfortwosessionsinarowanddonotrespondtomyattemptstoreschedule,Iwillassumethatyouhavedroppedoutoftherapyandwillmakethespaceavailabletoanotherindividual.

Youareresponsibleforpayingforyoursessionweeklyunlesswehavemadeotherfirmarrangementsinadvance.Myfeeforasessionis60.00.Ifwedecidetomeetforalongersession,Iwillbillyouproratedonthehourlyfee.Emergencyphonecallsoflessthantenminutesarenormallyfree.However,ifwespendmorethan10minutesinaweekonthephone,ifyouleavemorethantenminutesworthofphonemessagesinaweek,orifIspendmorethan10minutesreadingandrespondingtoemailsfromyouduringagivenweekIwillbillyouonaproratedbasisforthattime.Myfeeswillnotraisewhileyouareinsessionwithme.

Icurrentlydonotworkwithinsurancecompaniesforpayment;however,intheeventthatIdo,pleasebeawarethatyouareresponsibleforprovidingmewiththeinformationIneedtosendinyourbill.Youmustpaymeyourdeductibleatthebeginningofeachcalendaryearifitappliesandanyco-paymentateachsession.Youmustarrangeforanypre-authorizationsnecessary.Iwillbilldirectlytoyourinsurancecompanyviaelectronicmeansforyouonceamonth.Youmustprovidemewithyourcompleteinsuranceidentificationinformation,andthecompleteaddressoftheinsurancecompany.Ifacheckismailedtoyoutocoveryourbalancedue,youareresponsibleforpayingmethatamountatthetimeofournextappointment.Iftheinsuranceover-paysme,Iwillcreditittoyouraccountorrefundittoyouifyouwouldpreferthat. Page 10.


Iamnotwillingtohaveclientsrunabillwithme.Icannotacceptbarterfortherapy.Idotakecashorcreditcards.Anyoverduebillswillbecharged1.5%permonthinterest.Ifyoueventuallyrefusetopayyourdebt,Ireservetherighttogiveyournameandtheamountduetoacollectionagency.

Complaints

Ifyou'reunhappywithwhat'shappeningintherapy,Ihopeyou'lltalkaboutitwithmesothatIcanrespondtoyourconcerns.Iwilltakesuchcriticismseriouslyandwithcareandrespect.IfyoubelievethatI'vebeenunwillingtolistenandrespond,orthatIhavebehavedunethically,youcancomplainaboutmybehaviortotheArizonaBoardofBehavioralHealthExaminers.Youarealsofreetodiscussyourcomplaintsaboutmewithanyoneyouwish,anddonothaveanyresponsibilitytomaintainconfidentialityaboutwhatIdothatyoudon'tlike,sinceyouarethepersonwhohastherighttodecidewhatyouwantkeptconfidential.

Client Consent to Therapy

Ihavereadthisstatement,hadsufficienttimetobesurethatIconsidereditcarefully,askedanyquestionsthatIneededto,andunderstandit.Iunderstandthelimitstoconfidentialityrequiredbylaw.IfeverIuseinsuranceforpayment,Iconsenttotheuseofadiagnosisinbilling,andtothereleaseofthatinformationandotherinformationnecessarytocompletethebillingprocess.Iagreetopaythefeeof$60.00persession.Iunderstandmyrightsandresponsibilitiesasaclient,andmytherapist'sresponsibilitiestome.IagreetoundertaketherapywithKristiStuckwisch,LCSWLISAC.IknowIcanendtherapyatanytimeIwishandthatIcanrefuseanyrequestsorsuggestionsmadebyKristiStuckwisch.Iamovertheageofeighteen.

Clientname(Printed):__________________________________

Signed:______________________________________________Date:___________________

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Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for Psychotherapy

Thisformprovidesyou,theclient,withinformationthatisadditionaltothatdetailedintheNoticeofPrivacyPracticesanditissubjecttoHIPAApreemptiveanalysis.PURPOSEOFPSYCHOLOGICALSERVICESPsychotherapyisnoteasilydescribedingeneralstatements.Itvariesdependingonthepersonalitiesofthepsychotherapistandclient,andtheparticularproblemsyouareexperiencing.Therearemanydifferentmethodsand/orprocedureswemayusetodealwiththeproblemsthatyouhopetoaddress.Psychotherapycallsforaveryactiveeffortonyourparttoreflectcarefullyontheproblemsyouareexperiencing,tobemindfulofyoureffortsatsolutionsandwhytheydoordonotwork,andtobereadytomakesomechangesIyourlifethatmayormaynotbeeasy.Togetthemostfromtherapy,youshouldexpecttoworkontheseissuesinsessions,butalsoinbetweensessionsatworkandathome.Psychotherapycanhavebenefitsandrisks.Sincetherapyofteninvolvesdiscussingunpleasantaspectsofyourlife,youmayexperienceuncomfortablefeelingslikesadness,guilt,anger,frustration,lonelinessandhelplessness.Ontheotherhand,psychotherapyhasalsobeenshowntohavemanybenefits.Therapyoftenleadstobetterrelationships,solutionstospecificproblemsandsignificantreductionsinfeelingsofdistress.Buttherearenoguaranteesofwhatyouwillexperience,sointhatwaytheremaybelimitationsanduniqueresults.Ourfirstfewsessionswillinvolvetryingtogettoknowyou,understandingyourstrengthsandweaknesses,thecurrentproblemsyoufaceandwhathasbeenhelpfulandnotsohelpfulinthepastindealingwiththeseissuesMEETINGSWewillusuallyscheduleone50minutesessionperweek(orevery2weeks)atatimeagreedupon.Oneanappointmentisscheduled,youwillbeexpectedtopayforitunlessyouprovide24hoursadvancenoticeofcancellation.CLIENTRIGHTSHIPAAprovidesyouwithanumberofrights,whichbrieflyincludetherighttoAmendtheinformationinyourrecord,tolimitwhatinformationisdisclosedandtowhom,torequestrestrictionsastohowyouarecontacted,andtoreceiveAccountingofDisclosures,oralistofallinformationthathasbeenreleasedaboutyou.YoualsocanfileacomplaintaboutmypoliciesandproceduresregardingyourrecordswiththeFederalDepartmentofHealthandHumanServices.

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CONFIDENTIALITY&LIMITSONCONFIDENTIALITY:Thelawprotectstheprivacyofallcommunicationsbetweenaclientandapsychotherapist.Inmostsituations,wecanonlyreleaseinformationaboutyourtreatmenttoothersifyousignawrittenAuthorizationformthatmeetscertainlegalrequirementsimposedbyHIPAAand/orArizonalaw.However,inthefollowingsituations,noauthorizationisrequired:

• Ifyouareinvolvedinacourtproceedingandarequestismadeforinformationconcerningyourdiagnosisandtreatment,suchinformationisprotectedbythepsychotherapist-clientprivilegelaw.Wecannotdiscloseanyinformationwithoutacourtorderoryourwrittenconsent.Ifyoufileacomplaintorlawsuitagainstme,however,Imaydisclose,relevantinformationregardingourworkinmydefense.

• Ifagovernmentagencyisrequestinginformationaboutourworkforahealthoversightactivities,orifyoufileaworker’scompensationclaim,wemayhavetoprovideacopyofyourfiletoaStaterepresentative,youremployer,oranappropriatedesignee.

Asamandatedreporter,therearesomesituationsinwhichIamlegallyobligatedtotakeactionthatwilllikelyinvolverevealinginformationaboutoursessionstoanoutsideparty,possiblywithoutyourconsent.Thesesituationsinclude:

• whenthereisreasonablesuspicionofaminorchild,dependent,orelder(adultage65+)experiencingabuseorneglect

• whenaclientpresentsasaclear,imminentdangertoselfortoothers.Theseinvolvespecificthreatsofviolencetoselforothers.

Greatcareandattentionwillbegiventoasituationwhereaclient'sfamilymembercommunicatestomethatyoupresentasadangertoselforothers.Disclosuremayalsoberequiredpursuanttoalegalproceedingbyoragainstyou.Ifyouplaceyourmentalstatusatissueinlitigationinitiatedbyyou,thedefendantmayhavetherighttoobtainthepsychotherapyrecordsand/ortestimonybyme.Incouplesandfamilytherapy,orwhendifferentfamilymembersareseenindividually,evenoveraperiodoftime,confidentialityandprivilegedoapplyandspecificswillnotbedisclosed,unlessthepartiesprovidewrittenorverbalagreementtodoso.Iwillusemyclinicaljudgmentwhenrevealingsuchinformation.IwillnotreleaserecordstoanyoutsidepartyunlessIamauthorizedtodosobyalladultpartieswhowerepartofthefamilytherapy,couplestherapyorothertreatmentthatinvolvedmorethanoneadultclient.HEALTHINSURANCE&CONFIDENTIALITYOFRECORDS:DisclosureofconfidentialinformationmayberequiredbyyourhealthinsurancecarrierorHMO/PPO/MCO/EAPinordertoprocesstheclaims.Ifyousoinstructme,onlytheminimumnecessaryinformationwillbecommunicatedtothecarrier.Ihavenocontrolover,orknowledgeof,whatinsurancecompaniesdowiththeinformationshesubmitsorwhohasaccesstothisinformation.Youmustbeawarethatsubmittingamentalhealthinvoiceforreimbursementcarriesacertainamountofrisktoconfidentiality,privacyortofuturecapacitytoobtainhealthorlifeinsuranceorevenajob.Theriskstemsfromthefactthatmentalhealthinformationislikelytobeenteredintobiginsurancecompanies'computersandislikelytobereportedtotheNationalMedicalDataBank.Accessibilitytocompanies'computersortotheNationalMedicalDataBankdatabaseisalwaysinquestionascomputersareinherentlyvulnerabletohackingandunauthorizedaccess.Medicaldatahasalsobeenreportedtohavebeenlegallyaccessedbylawenforcementandotheragencies,whichalsoputsyouinavulnerableposition.

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RECORDSANDYOURRIGHTTOREVIEWTHEM:BoththelawandthestandardsofmyprofessionrequirethatIkeeptreatmentrecordsforatleast7years.Pleasenotethatclinicallyrelevantinformationincludessuchthingsas:whyyouareseekingtherapy,howyourcurrentproblemsnegativelyimpactyourlife,yourdiagnosis(ifoneisnecessary),ourtreatmentgoals,yourprogresstowardsthosegoals,anymedical/mentalhealthorsocialhistorywegather,anytreatmentrecordsorconsultationsIreceivefromotherprovidersregardingyourcase,anybillingrecordsandcontactinformationandanyreportsthatIreleasetoanyoneelse.Additionally,mypsychotherapynoteshelpdocumenttheareaswehavecovered,recordimportantinformationtoberememberedlater,andtrackifandhowtherapyishelpingyou.Thesenotescanincludethedatesandcontentsofourconversations,myanalysisofourconversationsandideasIwishtoexplorewithyouintherapy.Theyalsoincludeanyparticularlysensitiveinformationyourevealintherapy.Thesenotesarenotavailabletoanyoneelseunlessyouspecificallyauthorizetheirrelease.Unlessotherwiseagreedtobenecessary,IretainclinicalrecordsonlyaslongasismandatedbyArizonalaw.Ifyouhaveconcernsregardingthetreatmentrecords,pleasediscussthemwithme.Asaclient,youhavetherighttorevieworreceiveasummaryofyourrecordsatanytime,exceptinlimitedlegaloremergencycircumstancesorwhenIassessthatreleasingsuchinformationmightbeharmfulinanyway.Insuchacase,Iwillprovidetherecordstoanappropriateandlegitimatementalhealthprofessionalofyourchoice.Consideringalloftheaboveexclusions,ifitisstillappropriate,anduponyourrequest,Iwillreleaseinformationtoanyagency/personyouspecifyunlessIassessthatreleasingsuchinformationmightbeharmfulinanyway.Whenmorethanoneclientisinvolvedintreatment,suchasincasesofcoupleandfamilytherapy,Iwillreleaserecordsonlywithsignedauthorizationsfromalltheadults(orallthosewholegallycanauthorizesucharelease)involvedinthetreatment.LITIGATIONLIMITATION:Duetothenatureofthetherapeuticprocessandthefactthatitofteninvolvesmakingafulldisclosurewithregardtomanymatterswhichmaybeofaconfidentialnature,itisagreedthat,shouldtherebelegalproceedings(suchas,butnotlimitedtodivorceandcustodydisputes,injuries,lawsuits,etc.),neitheryounoryourattorney(s),noranyoneelseactingonyourbehalfwillcallonmetotestifyincourtoratanyotherproceeding,norwilladisclosureofthepsychotherapyrecordsberequestedunlessotherwiseagreedupon.CONSULTATION:Imayfinditnecessarytoconsultwithanotherprofessionalregardingmyclients;however,eachclient'sidentityremainscompletelyanonymousandconfidentialityisfullymaintained.Ifthisisevernecessaryforyourcase,Iwillprovideyouwithanauthorizationofwrittenconsenttosignoffon,despitethefactthatnoidentifyinginformationwillbediscussed.E–MAILS,CELLPHONES,COMPUTERS,ANDFAXES:. It is very important to be aware that computers and unencrypted email, texts, and e-faxes communication (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on my laptop and desktop is encrypted, emails, texts and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. My laptop and desktop are both equipped with a firewall, a virus protection and a password, and

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she backs up all confidential information from her computer on a regular basis onto an encrypted hard-drive. Please notify me if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and she will honor your desire to communicate on such matters. Please do not use texts, email, voice mail, or faxes for emergencies. PROFESSIONALFEESThehourlyfeeforindividualsessionsis$60persession,unlessanotheragreementismadepriortothestartoftherapyservices.Thisfeeincludesnotewriting,shorttelephoneconversations,shorttexts.Thefeeforinitialvisitsandsubsequentfollowupvisitsis$60per50minutes.Thefeeforjointsessionsis$75persession.Meaning,ifweagreetohaveanotherpersonjoinusduringyoursessiontimefortheentiresession,thefeeforthesessionwillbe$75.ThefeeforCouplestherapysessionsis$80per50minutesessions.PAYMENTS&INSURANCEREIMBURSEMENT:Clientsareexpectedtopaythestandardfeeof$60.00per50minutesessionattheendofeachsessionunlessotherarrangementshavebeenmade.Telephoneconversations,sitevisits,writingandreadingofreports,consultationwithotherprofessionals,releaseofinformation,readingrecords,longersessions,traveltime,etc.willbechargedatthesamerate,unlessindicatedandagreeduponotherwise.Pleasenotifymeifanyproblemsariseduringthecourseoftherapyregardingyourabilitytomaketimelypayments.Clientswhocarryinsuranceshouldrememberthatprofessionalservicesarerenderedandchargedtotheclientsandnottotheinsurancecompanies.Unlessagreedupondifferently,Iwillprovideyouwithacopyofyourreceiptonamonthlybasis,whichyoucanthensubmittoyourinsurancecompanyforreimbursement,ifyousochoose.Aswasindicatedinthesection,HealthInsurance&ConfidentialityofRecords,youmustbeawarethatsubmittingamentalhealthinvoiceforreimbursementcarriesacertainamountofrisk.Notallissues/conditions/problems,whicharedealtwithinpsychotherapy,arereimbursedbyinsurancecompanies.Itisyourresponsibilitytoverifythespecificsofyourcoverage.Ifyouraccountisoverdue(unpaid)andthereisnowrittenagreementonapaymentplan,Icanuselegalorothermeans(courts,collectionagencies,etc.)toobtainpayment.CANCELLATION:Sincetheschedulingofanappointmentinvolvesthereservationoftimespecificallyforyou,aminimumof24hours(1day)noticeisrequiredforre-schedulingorcancelinganappointment.Unlesswereachadifferentagreement,thefullfeewillbechargedforsessionsmissedwithoutsuchnotification.Mostinsurancecompaniesdonotreimburseformissedsessions.MEDIATION&ARBITRATION:Alldisputesarisingoutof,orinrelationto,thisagreementtoprovidepsychotherapyservicesshallfirstbereferredtomediation,before,andasapre-conditionof,theinitiationofarbitration.ThemediatorshallbeaneutralthirdpartychosenbyagreementofyouandI.Thecostofsuchmediation,ifany,shallbesplitequally,unlessotherwiseagreedupon.Intheeventthatmediationisunsuccessful,anyunresolvedcontroversyrelatedtothisagreementshouldbesubmittedtoandsettledbybindingarbitrationinMaricopa,AZinaccordancewiththerulesoftheAmericanArbitrationAssociationwhichareineffectatthetimethedemandforarbitrationisfiled.Notwithstandingtheforegoing,intheeventthatyouraccountisoverdue(unpaid)andthereisnoagreementonapaymentplan,Icanuselegalmeans(court,collectionagency,etc.)toobtainpayment.Theprevailingpartyinarbitrationorcollectionproceedingsshallbeentitledtorecoverareasonablesumasandforattorney'sfees.Inthecaseofarbitration,thearbitratorwilldeterminethatsum.

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THEPROCESSOFTHERAPY/EVALUATIONANDSCOPEOFPRACTICE:Asstatedearlier,participationintherapycanresultinanumberofbenefitstoyou,includingimprovinginterpersonalrelationshipsandresolutionofthespecificconcernsthatledyoutoseektherapy.Workingtowardthesebenefits,however,requireseffortonyourpart.Psychotherapyrequiresyourveryactiveinvolvement,honesty,andopennessinordertochangeyourthoughts,feelings,and/orbehavior.Iwillaskforyourfeedbackandviewsonyourtherapy,itsprogress,andotheraspectsofthetherapyandwillexpectyoutorespondopenlyandhonestly.Sometimesmorethanoneapproachcanbehelpfulindealingwithacertainsituation.Duringevaluationortherapy,rememberingortalkingaboutunpleasantevents,feelings,orthoughtscanresultinyouexperiencingconsiderablediscomfortorstrongfeelingsofanger,sadness,worry,fear,etc.,orexperiencinganxiety,depression,insomnia,etc.Imaychallengesomeofyourassumptionsorperceptionsorproposedifferentwaysoflookingat,thinkingabout,orhandlingsituations,whichcancauseyoutofeelveryupset,angry,depressed,challenged,ordisappointed.Attemptingtoresolveissuesthatbroughtyoutotherapyinthefirstplace,suchaspersonalorinterpersonalrelationships,mayresultinchangesthatwerenotoriginallyintended.Psychotherapymayresultindecisionsaboutchangingbehaviors,employment,substanceuse,schooling,housing,orrelationships.Sometimesadecisionthatispositiveforonefamilymemberisviewedquitenegativelybyanotherfamilymember.Changewillsometimesbeeasyandswift,butmoreoftenitwillbeslowandevenfrustrating.Thereisnoguaranteethatpsychotherapywillyieldpositiveorintendedresults.Duringthecourseoftherapy,Iamlikelytodrawonvariouspsychologicalapproachesaccording,inpart,totheproblemthatisbeingtreatedandhis/herassessmentofwhatwillbestbenefityou.Theseapproachesinclude,butarenotlimitedto,acceptanceandcommitmenttherapy,cognitive-behavioraltherapy,dialecticalbehavioraltherapy,psychodynamicapproaches,narrativetherapy,system/family,developmental(adult,child,family),humanisticorpsycho-educational.Iprovideneithercustodyevaluationrecommendationnormedicationorprescriptionrecommendationnorlegaladvice,astheseactivitiesdonotfallwithinhis/herscopeofpractice.TREATMENTPLANS:Withinareasonableperiodoftimeaftertheinitiationoftreatment,Iwilldiscusswithyouherworkingunderstandingoftheproblem,treatmentplan,therapeuticobjectives,andhis/herviewofthepossibleoutcomesoftreatment.Ifyouhaveanyunansweredquestionsaboutanyoftheproceduresusedinthecourseofyourtherapy,theirpossiblerisks,myexpertiseinemployingthem,oraboutthetreatmentplan,pleaseaskandyouwillbeansweredfully.Youalsohavetherighttoaskaboutothertreatmentsforyourconditionandtheirrisksandbenefits.EMERGENCY:Ifthereisanemergencyduringtherapy,orinthefutureaftertermination,whereIbecomeconcernedaboutyourpersonalsafety,thepossibilityofyouinjuringsomeoneelse,oraboutyoureceivingproperpsychiatriccare,IwilldowhateverIcanwithinthelimitsofthelaw,topreventyoufrominjuringyourselforothersandtoensurethatyoureceivethepropermedicalcare.Forthispurpose,Imayalsocontactthepersonwhosenameyouhaveprovidedonthebiographicalsheet.TELEPHONE&EMERGENCYPROCEDURES:Ifyouneedtocontactmebetweensessions,pleaseleaveamessageat480-241-8678andyourcallwillbereturnedassoonaspossible.Icheckmymessagesafewtimesduringthedaytimeonly,unlessIamoutoftown.Ifanemergencysituationarises,indicateitclearlyinyourmessageandifyouneedtotalktosomeonerightawaycallthecrisislineat(602)-222-9444,EmpactCrisisServices(480)784-1500orthePolice:911.Pleasedonotuseemailorfaxesforemergencies.Idonotalwayscheckmyemaildaily.

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DUALRELATIONSHIPS:Therapyneverinvolvessexualoranyotherdualrelationshipthatimpairsmyobjectivity,clinicaljudgmentorisexploitativeinnature.Iwillneverenterintonon-sexualandnon-exploitativedualrelationshipswithclients.Iwillneveracknowledgeworkingwithanyonewithoutyourwrittenpermission.Itisyourresponsibilitytoadvisemeifthereisanyconcernforpotentialdualormultiplerelationships.Iwillalwayslistencarefullyandaddressyourfeedback,seekinganethicalresolutiontothedilemmathatisinyourbesttherapeuticinterest.SOCIALNETWORKINGANDINTERNETSEARCHES:Idonotacceptfriendrequestsfromcurrentorformerclientsonsocialnetworkingsites,suchasFacebook.Ibelievethataddingclientsasfriendsonthesesitesand/orcommunicatingviasuchsitescancompromisetheirprivacyandconfidentiality.Forthissamereason,Irequestthatclientsnotcommunicatewithmeviaanyinteractiveorsocialnetworkingwebsites.TERMINATION:Ido not work with clients who, in my opinion, I cannot help. In such a case, if appropriate, I will give you referrals that you can contact. If at any point during psychotherapy Ieither assesses that I am not effective in helping you reach the therapeutic goals or perceive you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, I will discuss with you the termination of treatment and conduct pre-terminationcounseling. In such a case, if appropriate and/or necessary, I would give you a couple of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will give you a couple of referrals that you may want to contact, and if he has your written consent, I will provide you with the essential information needed. In order to provide a safe, respectful and pleasant experience for all clients and guests, there may be times where I need to terminate services with a client. Although this is something I rarely do, here are some reasons why I might be forced to do so: Threatening, rude or loud behavior by you or those accompanying you ; failure to pay your bill in a timely manner ; failure to follow recommendations of your therapist. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, I will provide you with names of other qualified professionals whose services you might prefer.IhavereadtheaboveOfficePoliciesandGeneralInformation,AgreementforPsychotherapyServicesorInformedConsentforPsychotherapycarefully(atotalof6pages);Iunderstandthemandagreetocomplywiththem:Client'sName(print)____________________________________________________________________Signature__________________________________________________________Date___________________KristiStuckwisch,LCSWLISAC,TherapistSignature_________________________________________________________Date___________________

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SpiritJourneyLLC KristiStuckwisch,LCSWLISAC3200N.Dobson,BldgCChandler,AZ85224Ph#480-241-8678

AuthorizationToDiscloseHealthInformationI,_______________________________________________,whoseDateofBirthis_____________________,authorizeSpiritJourneyLLCtodisclosetoand/orobtainfrom:Name___________________________________________________________________________________________Address:_______________________________________________________________________________________PhoneNumber:_________________________________________Onthisdate:____________________________________________thefollowinginformation:

DESCRIPTIONOFINFORMATIONTOBEDISCLOSED(ClientShouldInitialEachItemToBeDisclosed)

Assessment EducationInformation Demographic

Information Diagnosis ProgressinTreatment CurrentTreatment

Update Psychosocial

Evaluation Psychiatric

Evaluation TreatmentPlanor

Summary Medication

ManagementInformation

Presence/ParticipationinTreatment

Nursing/MedicalInformation

PsychotherapyNotes*

Court/LegalDocuments

Other:

DischargeSummary

TransferSummary Other:

(**Cannotbecombinedwithanyotherdisclosure)

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PURPOSEThepurposeofthisdisclosureofinformationistoimproveassessmentandtreatmentplanning,shareinformationrelevanttotreatmentandwhenappropriate,coordinatetreatmentservices.REVOCATIONIunderstandthatIhavearighttorevokethisauthorization,inwriting,atanytimebysendingwrittennotificationtoSpiritJourneyLLC,at2129E.VaughnAve,Gilbert,AZ85234.Ifurtherunderstandthatarevocationoftheauthorizationisnoteffectivetotheextentthatactionhasbeentakeninrelianceontheauthorization.EXPIRATIONUnlesssoonerrevoked,thisauthorizationexpiresonthefollowingdate:__________________Orasotherwiseindicated:______________________________________________________________________CONDITIONSIfurtherunderstandthatSpiritJourneyLLCwillnotconditionmytreatmentonwhetherIgiveauthorizationfortherequesteddisclosure..However,ithasbeenexplainedtomethatfailuretosignthisauthorizationmayhavethefollowingconsequences:________________________________________________________________________________________________________________________________________________________________________________________________________________FORMOFDISCLOSUREUnlessyouhavespecificallyrequestedinwritingthatthedisclosurebemadeinacertainformat,SpiritJourneyLLCreservestherighttodiscloseinformationaspermittedbythisauthorizationinanymannerthatisdeemedtobeappropriateandconsistentwithapplicablelaw,including,butnotlimitedtoverbally,inpaperformatorelectronically.REDISCLOSUREIunderstandthatthereisthepotentialthattheprotectedhealthinformationthatisdisclosedpursuanttothisauthorizationmaybere-disclosedbytherecipientandtheprotectedhealthinformationwillnolongerbeprotectedbytheHIPAAprivacyregulations,unlessaStatelawappliesthatismorestrictthanHIPAAandprovidesadditionalprivacyprotections.Iwillbegivenacopyofthisauthorizationformyrecords.

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______________________________________________ _________________SignatureofClient Date______________________________________________ __________________SignatureofPersonalRepresentative(ifnecessary) DateIfyouaresigningasapersonalrepresentative,pleasedescribeyourauthoritytoactforthisindividual(powerofattorney,healthcaresurrogate,etc.)

___________________________________________________________________________________________________________________________________________________________________________________________________________________Checkhereifyou(client)refusetosignauthorizationKristiStuckwisch,LCSWLISAC________________________________________Date__________________

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