Outpatient Services Consent Agreement for Freedom Therapeutic Services P.L.L.C. (FTS)

Naomi Smith

FreedomTServices@yahoo.com

Master Clinical Social Worker (LCSW)

Quality Mental Health Profession (QMHP)

WELCOME to FREEDOM THERAPEUTIC SERVICES (FTS). This document contains important information regarding my professional services, business policies and how it will affect you as a client.

THERAPEUTIC SERVICES

Psychotherapy is NOT easily described in general statements. There are many different methods I may use to deal with issues or concerns you may have. Psychotherapy calls for very active effort on your part. In order for the therapy to be successful, you will have to work on things we discussed both during our sessions and at home.

THERAPEUTIC SESSIONS

Each therapy session s scheduled for 45 minutes, per week. However, some sessions may require longer times or frequency. Once an appointment hour has been scheduled, you will be expected to keep that appointment, if you must cancel your appointment, please contact me within 24 hours of the appointment. As your therapist I will work with you to reschedule another session. I understand life can bring about unexpected challenges therefore we may need to reschedule appointments date & time.

PROFESSIONAL FEES

My hourly fee is $50.00. This amount is paid monthly, which equals $200.00 a month for 4, 45-minute sessions. You may choose to be seen bi-weekly; however, your 4 sessions must be completed with 60 days. If we meet more than 1x per week, additional sessions are 30 minutes for a fee of $35.00. I charge $35.00 an hour for other professional services you may need. Other professional services include but not limited to report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized (VIRTUAL ONLY), preparation of treatment summaries and any time spent performing any other services you may request of me.

BILLING AND PAYMENTS

You will be expected to pay for sessions or services prior to the appointments, unless we have agreed otherwise or unless you have insurance coverage that requires other arrangement. In situations of unusual financial hardship, I am willing to negotiate a fee adjustment or payment installment plan. This is a fee for service cooperation. NONE REFUNDABLE

CONTACT INFORMTION

You can contact me through my website (Ntsmithimsw.com) or email (Freedomtservices.com). All contacts made will be answered within 24 hours. If you are in crisis (homicidal suicidal, psychotic, hypermania) you must call 911 or go to the nearest emergency room and ask for the psychiatric department for a mental health evaluation to be admitted into their in-patient psychiatric unit for safety and future evaluation.

CONFIDENTALITY

Privacy of all communications between a client and a social worker is protected by law. I can only release information about our work to others with your written permission. However, there are exceptions which I am mandated by law to report.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony, if he/she determines that the issues demand it, I must comply with that court order.

There are some situations in which I am legally obligated to take action to protect others from harm even if I have to reveal some information about client’s treatment. For example, if I believe that a child (elderly person or disabled person) is being abused or has been abused, I must make a report to the appropriate state agency.

If I believe that a client is threatening serous bodily harm to themselves or another, I must take protective actions. These actions are, contacting the police, potential victim, contacting family members or others who can help provide protection and may need to seek hospitalization for the client. If a similar situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action.

YOUR RIGHTS

If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and you are free to end therapy with FTS at any time. You have the right to consider where you are as safe, non-judgmental kind and respectful care, without criticism or discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion or national origin.

INFORMED CONSENT FOR TREATMENT

I consent to assessments and therapeutic treatments for myself.

I understand that I have the right to withdraw consent at any time.

I understand that there are risks, benefits, and consequences associated with Telemental health, including but not limited to, destruction of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited abilities to respond to emergencies.

I understand that there will be no recording of any of the online sessions by either party. All information disclosed in sessions or written records or pertaining to the sessions are confidential and my not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

I understand that the privacy laws that protect the confidentiality of my protected health information also apply to Telemental Health unless an exception to confidentiality applies.

I understand if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may e determined that Telemental health services re not appropriate and a higher level of care as required.

I understand that during a Telemental health session, we could encounter technical difficulties, resulting in service interruptions. If this occurs, we will end and restart the session.

By signing this form, I attest that the above information has been read, understood, agreed and consented to.

I have read, understand and agree to the information provided above.

First Name *

Last Name *

Date of Birth *

Current Phone Number *

First Emergency Contact Number *

Second Emergency Contact Number *

Email *

Current Physical Address (cannot be PO Box) *

Signature of Consent *

clear

Date: * +

APPOINTMENT FORM

What brings you here? *

How old are you? *

What is your gender identity? *

Male

Female

Gay

Lesbian

What is your relationship status? *

Single

Married

Separated

Divorced

What type of therapy are you looking for? *

Do you consider yourself to be religious? *

Do you consider yourself to be spiritual? *

Are you seeking Christain Counseling? *

Have you ever been in therapy before? *

When was the last time you thought about suicide? *

What led you to consider therapy today? *

What are your expectations from your therapist? A therapist who… *

Are you currently experiencing any symptoms from your current issue? *

Are you currently taking any medication? *

How would you rate your current sleeping habits? *

How do you prefer to communicate with your therapist? Face to face or Phone? *

How did you hear about this website? *

SCHEDULE YOUR APPOINTMENT

REMINDER: Before submitting this form, kindly complete your appointment booking using Calendly below. Please note that scheduling your appointment confirms your acceptance of the $50 professional fee, ensuring a seamless booking process for you.