Informed Consent Form

Please read and sign below.

Welcome to my practice. Beginning therapy is an important decision, and I am glad I can be a part of that experience for you. If, after the first meeting, we decide to enter into a therapeutic relationship, it is important that you be aware of the protections and limitations of that relationship. We will review the following information together, and any questions regarding the information will be addressed. If you are not comfortable with both your rights as a client and my limitations as your therapeutic alliance, we can discuss other options for treatment.

Scope of Practice and Credentials

I am a Licensed Professional Counselor with an MA in Psychological Counseling with a license to practice in the state of Georgia #LPC004375. I am also a Somatic Experiencing® practitioner, a Certified Realization Process Teacher ™, a Certified Meditation Coach/Instructor, and a National Certified Counselor. I have been practicing since 2001 and have myriad specialty training and certifications. To read about all of my credentialing, specialized certification, and licensure, you can read more here.

Confidentiality

As a client, your privacy and rights to confidentiality are protected. Confidential information may be disclosed when you, the client, give written valid consent or when a legally authorized person consents on your behalf. Information you share with me may be entered into records in written form. All written documentation regarding your treatment will be secured in a private physical location or a HIPPA-compliant cloud destination. Information about you and your treatment will not be shared casually or publicly.

There are some limits to your rights to confidentiality. Information about your treatment may be shared during supervision or consultation with other professionals

and/or members of your treatment team. When this occurs, this information will be limited to only that which is necessary and relevant for the purpose of supervision or consultation. When possible, your identity will be protected.

State law and professional ethics require therapists to maintain confidentiality except for the following situations:

1. If there is suspected child abuse, elder abuse, or dependent adult abuse.

2. A situation in which a serious threat to a reasonable, well-identified victim is communicated to the therapist.

3. When the threat to injure or kill oneself is communicated to the therapist.

4. If you are required to sign a release of confidential information by your medical insurance provider.

5. If you are required to sign a release for psychotherapy records if you are involved in litigation or other matters with private or public agencies. Think carefully and consult with an attorney before you sign away your rights.

How Does Psychotherapy Work?

There are times when integrating psychotherapy, bodywork, and somatic meditation and therapy might be helpful. I tend to integrate the Realization Process™ embodiment techniques with Somatic Experiencing®, with talk therapy and Bowen Therapy concepts. Integrating them can take various forms of alternating treatment sessions, doing a series of one and then a series of the other, or doing all concurrently. Which model and modalities/interventions I employ will depend on your situation and will be done with your informed consent. Modalities/Interventions can include talk therapy, exercise, manual (hands-on) therapy, Somatic Experiencing®, Integrative Breathwork, Realization Process™, movement education, and somatic and analytical meditation. For clients working in psychotherapy, hands-on bodywork might be an option but will be added only with your informed consent.

All therapeutic work, including talk therapy, movement education, body awareness, and hands-on therapy, is strictly professional, not personal level. You have the right to withdraw from therapy at any time. After our initial session, I will inform you of my assessment of what I think I can be helpful with and what I may not be able to help with. This will include a treatment plan. If I feel I cannot help you, I will tell you that and provide referrals for you when possible.

While it is impossible to predict the exact outcomes of therapy, we will work together toward the goals that we establish. In addition to the work we do together online or as arranged in an office, I may suggest things for you to do between treatment sessions. In psychotherapy, it is not uncommon for clients to feel levels of all emotional states, including but not limited to sadness, anxiety, and fear, as well as joy, happiness, and love. Clients healing from physical conditions may be referred to adjunct services, including physical therapy, bodyworkers, and specialized medical services, and might feel some level of pain and discomfort while having certain interventions applied. Your feedback is very important.

Benefits and Risks of Treatment

There are many benefits to psychotherapy. These benefits have been established by scientific research but are sometimes difficult to monitor or pinpoint. I am responsible for ensuring that, for the most part, the benefits of your therapy outweigh the risks. I will always keep you informed, to the best of my ability, of any possible risks as we make treatment decisions together. I will also assist you in getting to another treatment resource if, at any time, you decide that you would like to make a treatment change. My belief is that any person who has a desire to heal and/or change can do so with proper help and support. Ultimately, the decision to make changes is yours. I am here to guide and assist you on your journey.

Unfortunately, there are no guarantees that any or all of your problems will be remedied by pursuing treatment with me. It is quite possible that you may experience stress, strained relationships, and other difficulties as a result of working in therapy, especially as you share painful feelings and thoughts that can cause unpleasant internal experiences. Growth is difficult, and often, things feel worse before they feel better. You may experience anxiety when challenged to make major life decisions and/or changes. It is helpful to talk about these issues as they surface.

Please know that change is slow, and often, patience is required by both the client(s) and therapist as this process continues.

Boundaries of the Therapeutic Relationship

The therapeutic relationship is unique to any other kind of relationship. For your protection and to preserve the integrity of our work, there are certain boundaries that are held in therapy. You are expected to come to therapy, live up to your financial obligations, and be honest in our work together. You will never be asked to engage in any kind of personal relationship with me, and I will be unable to do so with you. Although therapy work can be extremely personal and meaningful, the relationship will always remain professional. We will only meet at scheduled times. Even once therapy is terminated, we cannot have a relationship other than a therapist/client relationship. This ensures the preservation of the therapeutic relationship if you should ever choose to return to therapy. We can discuss any particular feelings you may have in response to these therapeutic boundaries. In fact, this is an important part of the therapy process if and when it becomes an issue.

OFFICE POLICIES Scheduling and Cancellations

I do all scheduling; therefore, any cancellations or appointment changes must go through me. The best way to reach me regarding scheduling is through text to (678) 428-2730 or emailing jencfinch.com. You may also leave a voice message if you would prefer that method.

As a courtesy, cancellations must be made at least 24 hours in advance in order to avoid being charged for the appointment time. Therapists schedule blocks of time. If someone doesn’t show up, we cannot see another client. That time is lost. Please note that no insurance companies reimburse for missed appointments. Also, because wireless communication is not 100% reliable, my policy is that no appointment should be considered canceled unless I confirm it in a written response. I would also appreciate a written confirmation that you have heard from me about appointment changes.

As an online therapist, I am fairly flexible regarding scheduling. However, I reserve the right at any time to charge in full for repeated occurrences of missed appointments and appointments not canceled within 24 hours of the scheduled time.

Payment Policies

You will be financially responsible for all services rendered. I do not participate with insurance companies and am not on insurance panels. If you plan to use insurance for reimbursement, you will be given a special receipt called a superbill at the end of the month with all necessary procedure codes for all sessions and payments made, and you will be responsible for filing with your insurance company. There is no guarantee that your insurance company will reimburse you. Please note that deductibles must be met before insurance pays any part of the bill. Payment is required at the time of the session. Payment can be made by using PayPal.com. You will be sent an invoice and can pay through PayPal services by setting up a personal account, paying with most major credit cards, or by other means that PayPal contracts with, such as Apple Pay and Venmo. Any billing or payment issues should be discussed with me immediately to resolve any problems and address any concerns.

If you are delinquent with payment, there will be a $25 monthly late fee after 30 days, assessed once a month thereafter until the bill is paid in full. I do not offer payment plans or sliding scale fees. You will be contacted by letter and/or phone to discuss payment delinquencies before your bill is turned over to a collection agency. After three months and three notices to you and without a response, your bill will be turned over to a collection agency.

My fee for a 60-minute appointment is $250.00. The frequency of treatment will depend upon your needs, scheduling, and the severity of your troubles.

Emergency Needs and Vacation

Upon occasion, an emergency situation arises. I try to make myself available for emergencies unless I am on vacation and out of reach. If, for some reason, you call and do not get a response and are experiencing a genuine emergency, you are advised to call 911 or go to your nearest mental health facility or emergency room, and I will be in touch with you as soon as I can. Ridgeview Institute has a 24-hour emergency walk-in assessment center. They can be reached at (770) 434-4567.

I tend to only work with individuals who are foundationally stable, i.e., not in acute crisis. If suicidality presents, I will help bridge your treatment to a higher level of care. If you require hospitalization, I will contact your current mental health professionals with your permission and help you find interim resources to ensure your stabilization. Once secure stabilization is rendered, we can resume outpatient treatment after assessing your status and needs. As an online therapist, I cannot ethically offer crisis counseling; this is non-negotiable, and your safety is paramount, and you will be discharged to a higher level of care.

Please be advised that I do not have an after-hours on-call service.

Privacy

In daily practice, I may use email, written correspondence, text, and cellular phone service. In all these instances, confidentiality will be protected to the best of my ability but is limited due to the risk of information being overheard or ending up in the wrong hands. Every precaution will be taken to protect your privacy.

Consent to TeleMental Health Services

I work as an online therapist. On occasion, we may make specialized arrangements to meet in person, but this is rare. Together, we will ultimately determine which modes of communication are best for you and if a referral to a face-to-face therapist is more suitable. Technology is constantly changing, and there are implications to utilizing text, email, video conferencing, website portals, electronic chat forums, and recommendations to websites or apps that we may not realize at this time. Feel free to ask questions, and please know that I am open to any feelings or thoughts you have about these and other modalities of communication and treatment.

Termination and Follow-up

Termination is an important process in psychotherapy. If you are ready to begin the process of terminating, we will discuss this at length and spend several sessions putting closure on our work together. Terminating treatment is usually up to the client. There are occasions, however, when I may initiate termination. The reasons for this decision will be discussed with you and will include an explanation. Possible reasons for a therapist terminating treatment include failure on your part to comply with mutually developed treatment goals and procedures, needing a higher level of care, needing transition to face-to-face in-person therapy, the realization that you are not benefitting from therapy; failure on your part to pay a bill; any violent, abusive, threatening, or litigious behavior on your part; and/or if the therapeutic relationship is compromised in any way due to unforeseen circumstances. Any non-voluntary termination will be accompanied by an appropriate referral.

I leave it up to you to call and request an appointment time. If you have a standing appointment and do not show up for two weeks in a row, I will call you one time and then take you off the schedule and consider you terminated. Unless arrangements are made, if you are a regular client but have not called to schedule an appointment for two months, I will consider you terminated. You can initiate a return to therapy at any time after termination.

Client Rights

You have the right to information regarding my training and professional credentials.

You have the right to be treated by me in a consistently competent, ethical and respectful manner.

You have a right to a personal, individual assessment of your treatment needs in which your expertise about yourself is as important as my professional opinion about you.

You have a right to referrals to other competent professionals and services when your treatment needs indicate it.

You have a right to ask questions about the approach and methods I use and to decline the use of certain therapeutic techniques.

You have the right to confidential treatment except in circumstances already described in this document.

You have the right to information regarding the anticipated length of treatment and prognosis if you stop treatment.

You have the right to stop receiving therapy from me without any obligation other than to pay for the services you have already received unless you are a danger to yourself or someone else.

You have a right to resume services following termination after assessment.

You have a right to discuss your treatment, concerns, questions, and complaints with me.

Interaction with the Legal System

I understand that I will not involve or engage my therapist in any legal issues or litigation to which I am a party at any time, either during my counseling or after counseling terminates. This would include any interaction with the Court system, attorneys, Guardian ad Litems, psychological evaluators, alcohol and drug evaluators, or any other contact with the legal system. In the event that I wish to have a copy of my file and I execute a proper release, my therapist will provide me with a copy of my record if it is within a 7-year period after termination. If I believe it necessary to subpoena my therapist, I would be responsible for his or her expert witness fees in the amount of $1,500.00 for one-half (1/2) day to be paid five (5) days in advance of any court appearance or deposition. Any additional time I spend over one-half (1/2) day would be billed at the rate of $375.00 per hour, including travel time. I understand that if I subpoena my therapist, he or she may elect not to speak with my attorney, and a subpoena may result in my therapist withdrawing as my counselor.

Ethics

I abide by the Codes of Ethics of the American Counseling Association (ACA), the American Mental Health Counselors Association (AMHCA), and the Georgia Composite Board of PC, SW, and MFT. You can find the specifics of each code of ethics at https://www.lpcaga.org/cpcs-code-of-ethics-and-forms respectfully. My intent is to help you. Please ask me any questions you have as you move through your healing journey.

I look forward to working with you. Kindly, Jennifer Finch, M.A., LPC, NCC, SEP

PLEASE SIGN AND COMPLETE THE ELECTRONIC FORM BELOW TO ACKNOWLEDGE THAT YOU HAVE READ AND UNDERSTAND THE INFORMATION DESCRIBED HEREIN AND THAT YOU HAVE DISCUSSED WITH ME ANY PART OF THE INFORMATION YOU DO NOT UNDERSTAND.

THE ORIGINAL COPY OF THIS DOCUMENT WILL REMAIN IN MY FILE; FOR A PERSONAL COPY, YOU ARE RESPONSIBLE FOR PRINTING ON YOUR OWN.

“I UNDERSTAND THE FINANCIAL POLICY. I ALSO UNDERSTAND THAT THIS PROVIDER IS NOT ON INSURANCE PANELS AND DOES NOT FILE INSURANCE CLAIMS.”