Counseling Information and Consent

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Please read the information provided. When you have read and understood the information, please e-sign at the bottom of the page.

· If you are in crisis or in danger CALL 9-1-1, this program is not designed for crisis, emergency treatment or response

1. I received my Master’s degree in Clinical Professional Counseling from Liberty University in 2017. I am a Licensed CPC in the State of Nevada. I provide individual and couples therapy.
2. I will start your session within 15 minutes of the scheduled start time, you must be in the ‘waiting room’. If you miss your session or are not signed on within the 15 minute period, your fee becomes NON-REFUNDABLE and NON-TRANSFERABLE. If I (Jeffrey J. LaSpina) am unable to keep our appointment, your fee is TRANSFERABLE to the next scheduled session. Pre-Paid fees are NON-REFUNDABLE in all cases but may be negotiated at MY option. Any refunds agreed to are provided by electronic means only using Zelle or PayPal. 
3. As a LCPC, I may consult with professionals in the field. The purpose of such consultation is to ensure that you are provided with the best possible care. All consultation is conducted in a strictly confidential manner. By signing this document, you are consenting to allow such consultation without further notification. 
4. All sessions are by pre-arranged appointment only. In the event of a life-threatening emergency, please call 911 or proceed to the nearest hospital emergency room.

Please note the general guidelines under which counseling is provided:

A. (for on-line appointments only) Clients should use the provided link to enter the waiting room, from a known location (e.g., not from your car in a parking lot or any moving vehicle) - for in-person, please be in the waiting room at the time of your appointment. 

B. (on line appointments) The exact address of your location, including any space / apartment / suite number should be known to the therapist and reported at the beginning of each tele-session

C. Each session will be 45-50 minutes in length.

D. Contents of all therapy sessions are considered to be confidential. Verbal information, audio or video recorded information, and written records about a client cannot be shared with any other party. Noted exceptions are as follows:

· Client Consent—If you authorize by written consent, I will release your records or other information to an individual or individuals of your choice.

· Duty to Warn and Protect—When a client discloses intentions or a plan to harm another identifiable person, the mental health professional is required by law to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities.

· Abuse of Children or Vulnerable Adults—If it appears to the counselor that there is a reasonable suspicion of abuse or neglect of a child (or vulnerable adult), or if a client states or suggests that he/she is abusing or has recently abused a child (or vulnerable adult), the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

· Minors/Guardianship–I do not treat minors at this point. 

· Court Orders—Occasionally, the court may attempt to obtain, by power of subpoena, the release of privileged information against the client’s wishes. In such cases, attempts are made to protect the client’s rights, but success at doing so cannot be guaranteed and we may be ordered to release information or take deposition.

· Consultation and Training—As mentioned previously, an exception to confidentiality occurs when I am discussing your case with other mental health professionals in the field. Again, all consultation is conducted in a strictly confidential manner and is done to ensure that you receive the best care possible. 

E. There is a limitation on confidentiality when providing therapy to couples or families. By e-signing this document, you are stating that you agree to these limitations which prevent me from 'keeping a secret' from others involved in your treatment (family members, spouse or other's included in your treatment as identified clients).

F. In order to provide the very best services possible, I compile information about clients as we work together. Often, I write case notes and may record sessions (audio and/or video) for consultation and training purposes. It is possible that I could use and discuss materials collected during our work together during consultation with other mental health professionals. All materials are subject to the strict confidentiality guidelines described in this document. By e-signing this form, you are consenting to allow materials collected during your sessions to be used and/or discussed during consultation with other mental health professionals. 

G. Fees for Services 

All payments are made to me (Jeffrey J. LaSpina) via Zelle or PayPal (to: jeff@laspinacounseling.com). If you have nether, I can send an ‘e-Invoice’ which will allow you to pay on-line using most major credit or debit cards. I WILL NEVER PERSONALLY COLLECT BANK OR CREDIT / DEBIT CARD INFORMATION.  ALL FEES MUST BE PAID AT LEAST 2 HOURS BEFORE THE SCHEDULED START TIME OF YOUR SESSION. All clients are required to give a 24-hour notice of cancellation to avoid being charged for a missed appointment.

H. Insurance

I currently accept Anthem. I will need to verify coverage before our first appointment. In order to do this I will need a scanned image or clear photo of the front and back of your current insurance card AND current, valid state issued ID before our first appointment. 

I have read and fully understand the nature and limits of the counseling services being offered. I have elected and voluntarily agree to participate under these conditions.

· If you are in crisis or in danger CALL 9-1-1, this program is not designed for crisis, emergency treatment or response