I. Treatment Information

Welcome. This form is designed to help you feel more comfortable with the therapeutic process and to explain certain policies and procedures adhered to by the clinicians and staff at the Jones Counseling Center, PLLC, herein referred to as JCC. If you have any questions or concerns, please discuss them with your therapist. 

The therapeutic relationship is one in which both the client and therapist have obligations to each other. Our obligation to you is to provide a supportive, nurturing environment, to assist you in meeting your goals for treatment, and to maintain client-therapist confidentiality, except in those circumstances outlined below. Your obligation to the therapeutic process is to be open about your expectations for treatment, to help determine goals for treatment, and to work on those issues being addressed. This may include various types of "homework." 

There are both benefits and risks to therapeutic treatment. Most people experience some degree of immediate relief after beginning treatment. However, some clients may initially feel worse before they notice improvement. Studies suggest family and friends may notice improvement before you do. Even with our best efforts, therapy may not provide the expected results. If at any time you feel your needs are not being met, please let your clinician know. We may need to redirect the course of treatment. If you feel you do not have a good client-therapist fit with the clinician you are working with, we will be glad to refer you to someone with whom you may be more comfortable. 

Clinicians at JCC utilize empirically validated treatment approaches to alleviate symptoms for a variety of disorders and results may be quickly achieved, depending on your particular needs. The length of treatment may be brief for minor issues or may last longer for more complex issues. Typically, clients are seen for therapy once weekly, but this may be more or less frequent depending on your needs. If you cannot keep an appointment, please provide at least 24 hours notice. If you need to get in touch with your clinician between sessions, please call the clinic at (469) 551-3716 and your call will be returned as quickly as possible. If you have an emergency, please call 911.

II. Clinician Information

I, Nolan Jones, have a Ph.D. in Counseling from Texas A&M University - Commerce. I am a Licensed Professional Counselor (LPC - License #73178) in the State of Texas. I have counseled children, adolescents, college students, couples, and adults. I have experience and professional training in a variety of therapy techniques and work most specifically with Cognitive Behavioral Therapy (CBT). 

Ill. Confidentiality 

It is your right that sessions will be kept private and confidential. However, there are conditions in which confidentiality may be violated. These include: 

1. Evidence abuse of a minor, elder, or mentally impaired individual. (It is important to note that in the state of Texas children under 17 may not have consensual sex [by law it is considered indecency with a child and therefore "child abuse''] and the state requires a therapist to breach confidentiality and report such activity to Child Protective Services. If your counselor is required to make such a report to CPS about your child, you will be informed as well.)

2. Evidence of imminent suicidal or homicidal intent.

3. You are a client referred by the court or an agency.

4. Your records have been subpoenaed by a court of law.

5. Your health insurance company (payer source) requires certain client information as dictated by law.

6. You are a client being treated by a practicum student, doctoral intern, or post-doctoral fellow in which case your sessions will be discussed with Dr. Jones, clinical supervisor.

7. Certain client information is submitted to a collection agency in order to collect the balance of an overdue account.

IV. Record Information

It is required that notes be kept for therapy sessions. These notes are privileged unless subpoenaed by a court of law. If you use insurance to pay for sessions, some insurance companies require copies of notes. If you would like to retrieve records from our office personally you will be required to submit a records request. The records request form can be provided at the office or through email. Once the request is submitted the turnaround time is typically seven business days. However, if your files have to be retrieved from one of our archive systems processing your request could take up to ten business days.

I acknowledge that, in the event the therapist become incapacitated, dies, or terminates his practice, it will become necessary for another therapist (P. Randel Duncan, LPC-S) to take possession of my file and records. By signing this information and consent form, I give my consent to allowing a licensed mental health professional selected by Nolan Jones to take possession of my file and records and provide me with copies upon request or to deliver them to a therapist of my choice.

I understand that the Jones Counseling Center cannot ensure the confidentiality of any form of communication through electronic media. Personal content sent via email is not secure and can be potentially compromised.  Therefore, by signing this consent form, I am acknowledging that the JCC will not be held liable for personal information that I, as the client, choose to send via email or text should my confidentiality be compromised.  

V. Release of Information

If information needs to be released it will only be done according to state law and with a written consent from the client indicating an informed consent of such release. Please request an Authorization to Release Records/Records Request Form from the office if you need your records to be released to a third party. In the case of marital therapy, the client is the couple, not individuals; therefore, all records can only be released when both parties consent in writing or if mandated by the court. Additional information is provided in our Privacy Policies document.

VI. Consent to Payment of Fees for Services Rendered

Payment of the balance is the responsibility of the client or the client's representative, parent, or guardian if he/she is under the age of 18 years of age. Payment is expected at the time of service. The cost of a therapy session is $125 unless otherwise prearranged with the counselor. Phone consultation fees are billed at the therapy session rate unless otherwise prearranged with the counselor. 

VII. Emergency Contact

I authorize the Jones Counseling Center, PLLC and/or my counselor to release information related to my health and safety to the individual listed as my emergency contact in the event of an emergency situation. 

VIII. Social Media Policy

To protect the boundaries of our relationship no connection will be created to any counselor's personal social media account such as Facebook, Twitter, LinkedIn, etc.

XI. Consumer Information and Complaints

A person who provides professional counseling services to clients must be licensed, unless exempted by state law. A consumer who wishes to file a complaint against an individual licensed by the board may use the following information:

NOTICE TO CLIENTS

The Texas Behavioral Health Executive Council investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology. Although not every complaint against or dispute with a licensee involves professional misconduct, the Executive Council will provide you with information about how to file a complaint. Please call 1-800-821-3205 for more information. The Texas Behavioral Health Executive Council's address is 1801 Congress Ave., Ste. 7.300 Austin, Texas 78701.

X. Consent to Services

I hereby give clinicians at the Jones Counseling Center, PLLC permission to provide appropriate therapeutic and psychological services, as necessary. I have read the consent to services, including the limits of confidentiality, and the Client Privacy Notice (HIPPA).  

If the client's parents are separated or divorced, or you have legal guardianship and are not the child's biological parent, proof of guardianship or medical rights must be provided before the first session. Likewise, if the therapeutic process is court ordered, the court order document must be provided before the first session. 

Clients being seen for therapy will be charged a $75.00 fee for missed appointments and for appointments not cancelled at least 24 hours before the appointment start time. If your appointment is the day after a holiday, notification to the office must be the first business day prior to the holiday or earlier. For any other arrangements to be honored the client must have documentation of the arrangement on file with JCC. There is also a charge for any paperwork that will require the clinicians time outside of your scheduled appointment. This includes, but is   not limited to disability paper work, letters, and forms of any kind. If you become involved in litigation requiring your therapist's participation, you will be expected to pay for the professional time even if your therapist is compelled to testify by another party. Thank you for your understanding. 

The minimum fee for a court appearance is $1200.00 and is charged in increments of $800.00 per half day. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 "express" charge. If the case is reset with notice of less than 72 business-hours, the client will be charged $500 (in addition to the original rate $1200). All fees are doubled if the therapist has to postpone or interrupt plans to go out of town. Phone calls to legal representation will be billed at double the normal rate and will be the responsibility of the client or responsible party.

I acknowledge I have read and understood the Jones Counseling Center Consent, PLLC to Services form in its entirety and agree to all terms set forth in this document. I have the opportunity to ask questions about these policies. I understand I have the right to revoke this consent, in writing, at any time. 

(For Minors Only) I give permission for this minor child(ren) to receive counseling without a parent or guardian present. I have the legal authority to seek and grant permission for professional services for a minor child, there being no legal decree disallowing my authority to assume such responsibility.

Privacy Practices for Personal Health Information

Purpose: This notice describes how psychological and medical information about you may be used and disclosed and how you may have access to this information. Please review carefully.

Summary: This notice describes how your Personal Health Information (PHI) is protected and how we may use and disclose this information. PHI is defined as personally identifiable information that relates to your past, present, and future health, treatment, and payment for health care services. Our staff, by law, has access to this information only when there is valid need, such as to confer with other health care providers or for purposes of submitting claims for services, and only information directly relevant to the need will be revealed.

Basic HIPAA Rights: The Health Insurance Portability and Accountability Act (HIPAA) affords certain privacy rights regarding the use and disclosure of your PHI. These include the right to:

        - Be informed of the potential use of your PHI and to limit those uses and disclosures of protected health information.

        - Receive this written notice explaining how we may use and disclose your protected health information, your rights under HIPAA's privacy rule, and our responsibilities under HIPAA.

        - A paper copy of this notice or to have your legally designated representative receive a copy of this notice. You are asked to acknowledge receipt of this notice (see Consent to Treatment form).

        - Amend your record, to restrict what information from you record is disclosed to others, and to receive an accounting of disclosures of this information that were made without you authorization, other than for treatment, payment, or health care operations.

        - Have your complaints about our policies and procedures recorded in these records.

As health care providers, we are making a good faith effort to see that you or your legal representative have received and acknowledged this notice of privacy practices.

Uses and Disclosures

I. Disclosures for Treatment, Payment, and Health Care Operations: We may use or disclose your protected health information for certain treatment, payment, and health care operations and purposes without your authorization. For instance, we may disclose protected information to your health insurer to receive reimbursement for your health care or to determine eligibility or coverage.

II. Uses and Disclosures Requiring Authorization: With your prior appropriate authorization, we may use or disclose protected health information for purposes outside of treatment, payment, and health care operations. Again, protected information will not be released for these purposes until proper authorization has been received from you for releasing this information. 

III. Modification and Revocation of Authorizations: You may revoke or modify all authorizations required for release of information (outside of treatment and payment operations) at any time, provided each revocation is in writing. Note that the revocation or modifications are not valid until we receive them. Note also that you may not revoke an authorization to the extent that (1) we have relied on that information or (2) if the authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer the right to contest the claim under the policy.

IV. Uses and Disclosures with Neither Consent nor Authorization: We may use or disclose protected health information without your consent or authorization in the following circumstances:

        - Child Abuse: Whenever a clinician, in his/her professional capacity, has knowledge of or observes a child whom he/she knows or reasonably suspects has been the victim of child abuse or neglect, he/she must immediately report such to a police or sheriff's department, county probation department, or county or state welfare department.

        - Adult, Elder, and Domestic Abuse: If a clinician, in his/her professional capacity, has observed or has knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if the clinician is told by an elder or dependent adult that he or she has experienced these, or if the clinician reasonably suspects such, he/she must report the known or suspected abuse immediately to the local ombudsman or a local law enforcement agency.

        - Health Oversight: The State Licensure Board has the authority to subpoena confidential mental health information from a clinician relevant to any complaint made against me.

        - Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that have been provided to you, we must not release your information without:

               1. Your written authorization or the authorization of your attorney or personal representative, or

               2. A court order

(The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. We will inform you in advance if this is the case.)

        - Serious Threat to Health or Safety: If you communicate to a clinician serious threat of physical violence against an identifiable victim, the clinician must make reasonable efforts to prevent harm, which may include communicating that information to the potential victim and the police. If the clinician has reasonable cause to believe that you are in such a condition as to be dangerous to yourself or others, he/she may release information as necessary to prevent the threatened danger.

Patient Rights and Provider Duties

Patient Rights: You, the patient, have the following rights:

        - Right to Request Restrictions: you have the right to request restrictions on certain uses and disclosures of protected health information about you. Note, however, that we are not required to agree to a restriction you request.

        - Right to Receive Confidential Communications by Alternate Means and at Alternate Locations: you have the right to request and receive confidential communications of protected health information by alternate means and at alternate locations. (For example, you may not want a family member to know that you are seeing one of our clinicians. Upon your request, your bills will be sent to another address.)

        - Right to Inspect and Copy: you have the right to inspect or obtain a copy or both of protected health information in my mental health and billing records used to make decisions about you for as long as the protected information is maintained in the record. We may deny your access to protected information under certain circumstances, but in some cases you may have this reviewed. We will discuss with you the details of the request and denial process if you wish.

        - Right to Amend: you have the right to request an amendment of protected health information for as long as this information is retained in the record. Note that we may deny your request. We will discuss the details of the amendment process if you wish.

        - Right to an accounting: you generally have the right to receive an accounting of disclosures of protected information for which you have neither provided consent nor authorization (Section IV, above). If you wish, we will discuss the details of the accounting process.

        - Right to a Paper Copy: you have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to receive the notice electronically.

Provider Duties:

        - Your clinician is required by law to maintain the privacy of protected health information and to provide you with a notice of my legal duties and privacy practices with respect to protected information.

        - We reserve the right to change the privacy policies and practices described in this notice if we notify you of such changes.

        - If we revise our policies and procedures, we will provide you with a written copy of the revised policies and procedures at the earliest possible opportunity following this revision, either in person or by mail.

Complaints:

If you are concerned about possible violations of your privacy rights or you disagree with decisions we have made about access to your records, please contact Nolan Jones, Owner of Jones Counseling Center, PLLC. You may also file a complaint with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The web address for the Secretary of the Department of Health and Human Services is: https://www.hhs.gov/hipaa/filing-a-complaint/index.html

Restrictions and Changes to Privacy Policy:

We reserve the right to change the terms of this notice and to make the new notice provisions effective for all protected health information that we maintain. We will provide you with a revised notice by mail at the earliest opportunity following the revision.

Trust is critical in the provision of mental health services. We recognize that you are entrusting us with personal health information and protection of that information is important to your trust and peace of mind. We have given much thought to these policies and continue to exercise due care in protecting the security of your records. Thank you for your continued confidence in us.

I acknowledge receipt of the Patient Privacy Notice for the Jones Counseling Center, PLLC (and it's clinicians/counselors) and consent to the use and disclosure of my personal health information for treatment, payment or health care operations, as described in the Patient Privacy Notice.

Client Rights

As a client, you have the right to:

- Select a professional counselor who meets your needs.

- Receive specific information about your counselor's qualifications, including education, experience, national counseling certifications, and state licensure.

- Obtain a copy of the code(s) of ethics your counselor must follow.

- Receive a written explanation of services offered, time commitments, fee scales, and billing policies prior to receipt of services.

- Understand your counselor's areas of expertise and scope of practice (e.g., career development, adolescents, couples, etc.).

- Ask questions about confidentiality and its limits as specified in state laws and professional ethical codes.

- Receive information about emergency procedures (e.g., how to contact your counselor in the event of a crisis).

- Ask questions about counseling techniques and strategies, including potential risks and benefits.

- Establish goals and evaluate progress with your counselor.

- Request additional opinions from other mental health assessment professionals.

- Understand the implications of diagnosis and the intended use of psychological reports.

- Obtain copies of records and reports.

- Terminate the counseling relationship at any time.

- Share any concerns or complaints you may have regarding a professional counselor's conduct with the appropriate professional counseling organization or licensure board.

Client Responsibilities

In order for your counselor to provide the highest quality of services, it is important that clients:

- Adhere to established schedules. If you must miss an appointment, contact your counselor as soon as possible.

- Pay your bill in accordance with the billing agreements.

- Follow agreed-upon goals and strategies established in sessions.

- Inform your professional counselor of your progress and challenges in meeting your goals.

- Participate fully in each session to help maximize a positive outcome.

- Inform your counselor if you are receiving mental health services from another professional.

- Consider appropriate referrals from your counselor.

- Avoid placing your counselor in ethical dilemmas, such as requesting to become involved in social interactions or to barter for services.