Client Information Form

Welcome to our Counseling Center.  We are pleased to have the opportunity to serve you through Christ-centered individual, couple and family therapy.  Our mission is to be an outreach of Asbury Church to its members and surrounding area.  We desire to help transform lives filled with emptiness, pain, confusion, and despair.  As our client(s), you will experience compassion, expertise in the treatment of psychological and relational issues, and the life changing power of Jesus Christ.

Practical Issues

As our client(s), you have the right to be informed about the therapy program you will be engaged in.  These rights include:

1. The right to ask questions about therapy.  Your therapist will explain his/her therapy approach and methods used upon request.
2. The right to end therapy at any time without any moral, legal, or financial obligations other than those already incurred.
3. The right to know the Code of Ethics followed by your therapist.
4. The right to specify and negotiate therapeutic goals and to renegotiate them when necessary.
5. The right to be fully informed of the limits of confidentiality in the therapy setting.
6. The right to know if there has been no session activity or phone contact recorded for a period of 4 weeks, your client file will automatically closed.  In most circumstances, a client file can be re-opened upon completion of a new intake and payment of any delinquent fees.

Appointments

Appointments are usually scheduled for 50 minutes, commonly known as a “clinical hour”.  Your therapist will schedule your appointments and provide a reminder card.  If you should need to cancel or reschedule an appointment, please call 942-1491 at least 24 hours in advance.  Your therapist reserves the right to charge a $40.00 fee for canceled or missed appointments if not notified in advance.  If appointments are rescheduled more than 3 times, your therapist may request a referral to another agency.

Fees

The Asbury Counseling Center does not accept insurance at this time; however, our fees are comparable to those of insurance co-payments.  You will be informed of your payment by the use of a sliding scale.  If you attend Asbury Church and have financial hardships, financial assistance may be available upon application.  Also, additional fees may apply if your therapist is required to be present in court or provide court-related documents on your behalf.

Confidentiality

Because of the personal nature of information revealed in therapy, every effort will be made to respect the confidentiality of every client.  The information from the therapy sessions will remain confidential with the therapist within the guidelines established by Kansas State regulations.  By State Law, the rights of confidentiality do not apply under the following conditions.

1.   When a client may be a danger to him or herself or to others;
2.   When a child, elderly, or disabled person may be subject to abuse or neglect;
3.   When a court order exists or the therapist or records are subpoenaed by the court.

Should any of the above situations occur, your therapist will inform you of his/her responsibilities and actions.

Information about your case and treatment may be released to a third party only when all participants involved in therapy sign an “Authorization & Request for Release of Confidential Information and Privileged Communication” form.  Where a minor is receiving services, the appointment of a guardian ad litem may be necessary prior to the release of the minor’s information.  A release may also need to be signed to contact medical professionals on possible physical/biological conditions which may be causing psychological problems.  You do have the right to waiver this release if you so choose.

Benefits and Risks

Any time you seek therapy to work with the difficulties in your relationships; there are benefits and risks involved in the changes that may occur.  The benefits of therapy can include the ability to handle or cope with marital, family, and other interpersonal relationships in a healthier way.  You may also gain a greater understanding of personal and family goals and values.  This new understanding may lead the way to greater maturity and happiness as an individual, couple, or family.  In addition, there may be benefits that come as you work at resolving the specific concerns you have brought into therapy.

However, therapy can be challenging and uncomfortable at times.  Remembering and resolving unpleasant events may cause intense feelings of fear, anger, depression, frustration, and the like.  As you work to resolve issues between family members, marital partners, and other persons, you may experience discomfort and an increase in conflict.  There may be changes in your relationships you had not originally intended.

Your therapist will discuss with you the benefits and risks involved in your particular situation.  You are encouraged to discuss with you therapist any concerns you have as your therapy progresses.

Emergencies

If a client is in crisis, an on-call therapist can be contacted after hours at 316-466-2521.  This is to be used for emergency purposes only.

Asbury Counseling Center ~ ph. 316-942-1491 ~ fax 316-942-9895 ~ www.asburychurch.org