Introduction

This document provides important information about counseling and behavioral health

services with Kirksey Counseling and Behavioral Health, LLC. Information on your rights

as a client, the nature and limits of confidentiality, and what you can expect from the

counseling process. Please read this consent form carefully. If you have any questions,

do not hesitate to ask your therapist.

Nature of Counseling and Behavioral Health Services

Counseling is a collaborative process in which you and your therapist work together to

address personal, emotional, behavioral, or mental health concerns. The goals of

counseling may include developing coping strategies, improving relationships,

increasing self-awareness, and fostering personal growth.

Behavioral Health encompasses a broader array of services affecting well-being, and

can include substance use, exposure to critical incidents, and lifestyle concerns.

Potential Risks and Benefits

Therapy can lead to positive changes, such as improved mood, better relationships, and

enhanced coping skills. However, you may also experience uncomfortable emotions or

discuss difficult topics. These feelings are a normal part of the therapeutic process and

can be addressed in sessions. Your therapist will work with you in addressing difficult

conversations and will create a safe space before broaching a conversation.

Confidentiality

Your privacy is very important. Information shared in therapy sessions is confidential

and will not be disclosed without your written permission, except in the following

situations:

• If you pose a threat of harm to yourself or others

• If there is suspected abuse or neglect of a child, elderly person, or vulnerable

• adult

• If required by court order or applicable law

Your therapist will discuss confidentiality and its limits with you at your first session. By

signing this consent form, you are acknowledging that you understand the limits of

confidentiality and have discussed confidentiality with your therapist.

Participation and Voluntary Consent

Your participation in therapy is voluntary. You may withdraw from therapy at any time,

and you have the right to refuse any services or recommendations. If you are referred to

our office by your workplace, it is still your decision on participating. Information shared

with your workplace will be discussed in advance with your therapist and a release of

information stating what information can be shared will be signed. Information shared

with your workplace will usually include: number of sessions attended and progress.

What you discuss in your sessions will NOT be shared with your employer, unless you

specify that you want the information shared; and the release of information form will be

updated to reflect information being shared. Your therapist will respect your decisions

and discuss alternative options if needed.

Fees and Payment

Fees for therapy services, payment methods, and cancellation policies will be discussed

with you before starting services. If you have questions about costs, please ask your

therapist or contact our office at 614-800-2745.

Most commercial insurance plans provide coverage for mental and behavioral health

services. Our office makes every effort to gain a clear understanding of your benefits,

including co-pays and patient liability before starting this process. We encourage you to

also have a clear understanding of your benefits prior to starting therapy. We are

committed to working with you on your financial obligation and will discuss how co-

payments and patient liability are handled during the initial session.

Record Keeping

Kirksey Counseling and Behavioral Health LLC, contracts with a third-party company

with expertise in maintaining confidential mental health electronic records. A clinical

record is maintained describing your condition, treatment progress, treatment planning,

goals, dates of and fees for sessions. Your records will not be released without your

written consent, except in those situations outlined in the Confidentiality section above.

Cancellations and Missed Appointments

Clients are billed for sessions that are canceled with less than 24-hour notice. You can

leave messages 24 hours a day at 614-800-2745. A fee of $25.00 will be charged for

missed sessions without appropriate notice. We appreciate the courtesy you extend to

our practice by honoring this agreement. Please note that we cannot bill your insurance

for missed sessions. Not making your co-payments and other payments in a timely

manner may result in sessions being suspended until fees are paid.

Client Portal / Social Media

You will have an opportunity to create an account on our patient portal. The portal will

allow you to complete electronic documents prior to appointments and can be used to

request and cancel appointments. Your therapist may also use the portal to send you

handouts and self-assessments. You can also receive generic text messages reminding

you of appointments 24 hours in advance. Your therapist will not use texting to discuss

clinical matters, as texting is not confidential. If you need to share information with your

therapist between sessions, we ask you either call or email. Generally, we ask our

therapists to limit their involvement on social media to platforms used for professional

purposes. It is viewed as unprofessional for your therapist to engage in a relationship

with a client on other forms of social media.

We use Artificial Intelligence (AI) to assist in generating documents and therapy notes. If

you are opposed to the use of artificial intelligence, please let your therapist know and

we will respect your wishes. If you are not on social media, or prefer to have all

paperwork completed in person, we will honor your request.

Complaints

You have the right to have your complaints heard and efforts made to resolve your

complaints in a timely manner. If you have complaints about your treatment, therapist,

or any office policy, we ask that you first bring the complaint to the attention of your

therapist, followed by our senior therapist. If you still feel that the complaint was not

resolved, you can file a complaint with your insurance provider, or with the State of Ohio

Counselor and Social Worker Board.

Contact and Emergencies

Therapist may not be available outside of scheduled sessions. If you are experiencing

an emergency or crisis, please contact emergency services (911), a local crisis hotline

(988), or go to the nearest emergency room.

Client Rights

• To be treated with respect and dignity

• To receive information about therapy methods and approaches

• To ask questions and express concerns

• To end therapy at any time