Informed Consent


Client Information and Counselor-Client Contract

 

Lisa Rains-Mitchell, Nationally Board Certified Counselor (NBCC), M.Ed.

I am in private practice through God is Healing.com/Hospitality Healing Home. I hold a master's (M.Ed.) degree in counsling from the University of Mississippi. The graduate program I completed is accredited by the Council on Accreditation of Counseling and Related Educational Programs (CACREP).

I provide services for clients (women and their families) in my private practice who I believe have the capacity to resolve their own problems with my assistance. A counseling relationship between a Professional Counselor and client is a professional relationship in which the Professional Counselor assists the client in exploring and resolving difficult life issues.

In the event you feel your mental health requires emergency attention or if you have an emotional crisis, you should contact the emergency room or the crisis hotline.

I take privacy and confidentiality very seriously. For your protection, if I should see you outside of our scheduled meeting time I will not speak to you or seek you out unless you approach me first. My profession stands firm in that you will be best served if our relationship stays strictly professional and if our sessions concentrate exclusively on your concerns during your scheduled session times. Additionally, I am required not to accept any outside invitations, gifts, or additional relations.

I will keep confidential anything you say to me with the following as exceptions:a) you direct me to tell someone else, b) You have made it clear to me that you are a danger to yourself or others, or c) I am ordered by a court to disclose information. If I am ever ordered to disclose information, my personal beliefs and professional ethics requires that my notes are PROCESS oriented with few if any specifics, and that the information I yield pertain to specific questions asked.

My practice includes working with children, adolescents, adults and the elderly and includes career, personal, couples, marriage and family, and group counseling. I am also available for divorce mediation.

In return for a fee of $65.00 per session, I agree to provide counsling services for you. Session times are 50 minutes in duration. I assure you that my services will be rendered in a professional manner consistent with the accepted ethical standards.

The fee for each session will be due and must be paid at the conclusion of each session. Cash or personal checks are acceptable forms for payment. If online or telephone counseling from a distance is what we agree on, there is a paypal method of payment set up. In the event you will not be able to keep an appointment, you need to notify me 24 hours in advance or be responsible for paying half of the session you missed.

If you are a member of HMO, PPO, or some type of managed health care plan, I can tell you as of now I am not a provider of services under these plans. Fees will be billed and collected according to the requirements of most plans. However, your plan will not reimburse you. Plans often only reimburse for a limited number of visits per year. Our normal session length is at or below what most sessions would cover. Health insurance companies usually require that I diagnose your mental condition and indicate that you have an "illness" before they will agree to reimburse you. I will only discuss diagnosis criteria if it is of helpful interest to you.

If you have any questions at any time during our counseling process about areas this form has covered, or any other questions, please ask. By your signature below (please sign two copies, keep one for your files and return the other copy to me), you are indicating that you have read and understoo this statement, and/or that any questions you have had about this statement have been answered to your satisfaction.

 

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Lisa C. Rains-Mitchell                                                                            Client Name

 

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 Date                                                                                                          Date

 

Contact Us

Lisa: (662) 380-0938