Welcome: Before starting counseling, it is important to know what to expect, and to understand the patient's rights and commitments. This consent form is designed to be transparent about the counseling process, so the patient is fully informed prior to starting their journey.

What to Expect from Counseling: I strive to create a warm and inviting counseling environment for my patients and believe it is a privilege to support their journey of self-discovery and growth. Counseling is a confidential process designed to help the patient discuss their concerns, come to a greater understanding of themselves, and learn effective personal and interpersonal coping strategies. It involves a relationship between the patient and a trained therapist who has the desire and willingness to help the patient accomplish their individual goals.

Counseling involves sharing sensitive, personal, and private information that may sometimes be distressing. During counseling, there may be temporary periods of increased discomfort. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. I will be available to support the patient throughout the counseling process.

Fees: Individual counseling and parent consultation is billed at the rate of $140.00 for a 50-minute session. A $15.00 discount will be given for cash payments ($120.00/session).

Family counseling is billed at the rate of $155.00 for a 50-minute session. A $15.00 discount will be given for payments in cash ($140.00/session). Sessions are paid by credit card, HSA, or FSA cards.

Cancellation Policies: I, the patient, agree to pay the stated fee by cash or credit card at the end of each session. I understand that I must keep a credit card on file in my patient portal even if I choose to pay in cash. If I, the patient, am prevented from attending my scheduled session and do not cancel my appointment at least 24 hours in advance, I agree to pay the full session fee of $140.00. It is standard practice in the field to charge for no-shows or late cancellations. This takes into account that you are not just paying for services rendered, but also reserving a time slot which I cannot offer to someone else on short notice. If your child is the one scheduling their appointments, please inform them of this policy as well.

Collateral Contact: Some patients may benefit from me working collaboratively with other professionals and providers who work closely with the patient (pediatricians, teachers, school counselors, other therapists, etc.). 30 minutes per week of collateral contact is built into each session price. However, if more than 30 minutes of collateral contact is needed in a week, the patient/guardian will be billed at half-hour increments at a rate of $70.00.

Online Counseling Option: Online counseling is a relatively new development in mental health in which counseling is provided over the Internet through a secure video portal. Although in-person counseling develops a more personalized connection, time constraints, distance, pandemics, and other life situations can get in the way of preferred in-person treatment.

For online counseling, I use a quality internet provider that minimizes the chance of conferencing interruptions. If you choose video counseling, it is recommended that you have a reliable internet service (not cellular). Full session fees will be charged regardless of any technology problems that cause any interruptions in your session. It is also recommended that the patient has a quiet space free from distractions for all online sessions.

Insurance: I do not accept payment from health insurance plans. However, some insurance companies may reimburse part of the patient's counseling expenses if you have out-of-network coverage for behavioral or mental health. Upon request, I am happy to provide you with an emailed receipt that you can include when filing an insurance claim with your insurance company.

Out-of-network reimbursement is often contingent on receiving a medical or mental health diagnosis and certain diagnoses may not qualify. I do not accept responsibility for collecting payment from your insurance company and cannot guarantee that you will be reimbursed or that you will qualify for a reimbursable diagnosis. Please contact your insurance provider before services are rendered to find out if you have out-of-network coverage and bring any necessary forms to your first appointment.

Confidentiality: The information the patient shares with me during counseling sessions is considered confidential information and is protected by state law. As a mental health counselor, I cannot reveal to third parties whether or not the patient is a past or current patient of Youthrive Counseling and cannot disclose any of the information the patient discussed during our sessions without first obtaining the patient's written consent to do so.

In the following instances, however, I may be mandated or allowed to share information without your written consent:

 - If the patient talks about events that led me to believe that a child under the age of 18, an elderly person, or a disabled person is at risk for emotional, physical or sexual abuse, neglect, or exploitation, I am required by NY State law, as a mandated reporter, to make a report to New York Family and Protective Services with or without your consent.

 - If the patient is not yet 18 years of age, the patient's parents or legal guardians may have access to their records and may authorize release of information to other parties on the patient's behalf.

 - If the patient discloses sexual misconduct by a previous counselor/therapist, I am required to make a report to the licensing board governing the license of the therapist.

 - If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena. (I do not respond to any inquiries without written consent by the patient or patient's guardian to release information).

 - If I need to cooperate with legal actions against a mental health professional by a licensing board.

 - If the patient/guardian submits an out-of-network health insurance claim and the insurance provider needs information to authorize the counseling or the billing.

 - If during the patient's counseling, the patient is deemed to pose a threat of harm to someone else or to themselves, I am allowed to collaborate with the police or a hospital to take necessary measures to prevent harm from happening.

Professional Records: All counseling records are kept on a secure server and under double lock and key. Records will not be released without your written permission except as mandated by law. The patient/guardian is entitled to receive a copy of your records with a written and signed request.

Voicemails, emails, faxes, instant messages, and video sessions are kept in the highest confidentiality within the limits of the technology, but confidentiality is not and cannot be guaranteed. Any computer files kept regarding counseling communications are maintained using secure measures.

Emergencies and Regular Contact: If the patient is having an emergency, please call 911, or the 988 or 211 lifelines for immediate support. I keep afternoon and evening office hours Monday through Thursday. The patient/guardian can contact me at no charge by text, call, or email for any reason relating to counseling and the patient's mental health. I am not always available to answer calls immediately during office hours, as I do not take calls during sessions, but will return your call promptly.

Between-session contact is not a substitute for therapy or parent consultation sessions. If you or your child have frequent questions and concerns between sessions, or if contact becomes excessive/inappropriate, I will notify you and recommend additional session time where this can be addressed. Continued between-session contact will then be treated as Collateral Contact and billed in half-hour increments.

Email & Text Notifications: When appointments are scheduled, automated email/text reminders for the patient's appointment will be sent to the patient/guardian when scheduling the patient's first appointment. By signing this consent form, I agree to receive these notifications and understand that email/text is not a confidential medium for transmitting health care information.

The Scope of My Services: I am qualified to work with a wide variety of patients and problems, but sometimes I may not have the training needed to address a particular concern. If this is the case, I will discuss it with the patient/guardian and make sure that the patient receives a referral to another professional who is better qualified to meet the patient's needs. In addition, if the patient is having current hallucinations, delusions, severe psychosis, severe thoughts/actions of suicide or self-harm, or extreme bipolar mood swings the patient may need more support than I can offer the patient through weekly psychotherapy. I reserve the right to refer the patient to a different or more intensive treatment if I believe the patient exceeds the level of care I can offer.

I have thoroughly read the above information. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a patient of Leigha Smith, LMHCP.

I, the patient, consent to the above terms and agree to mental health treatment with Leigha Smith, LMHCP.