Trauma Detox

Danielle West

12001 W Parmer Lane Suite 200

Cedar Park TX 78613

I am honored that you have selected me as a therapist, and I look forward to assisting you.  This document is designed to inform you about what you can expect from me regarding your treatment. Communication with you is part of my commitment to keep you fully informed of every part of your therapeutic experience.  Please know that your relationship with me is a collaborative one, which means that you will be doing some of the work, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.  If your minor adolescent is the client, you are completing this consent on their behalf.   

Background Information

The following information regarding my educational background and experience as a therapist is an ethical requirement of my profession.  If you have any questions, please feel free to ask.  I received my undergraduate degree in Philosophy at the University of Colorado.  I then apprenticed with a plastic surgeon and took my LSAT to go to law school.  In a turn of events, I obtained a Master's degree in Counseling at the LeTourneau University, certification in trauma model therapy, and EMDR certification. I have studied dissociation my whole life and have experienced stabilizing and treating DID and BPD for 30 plus years through experiential work. I have what can't be bought through an education; that is real life research and practice.

Client Participation

Your goals in therapy of self-awareness, self-acceptance, and problem solving may take a long time to achieve.  Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy.  As a client, you are in complete control, and you may end your relationship with me at any point.  You are the most important member of your treatment team. 

In order for therapy to be most successful, it is important for you to take an active role.  This means working on the things you and I talk about both during and between sessions.  Generally, the more of yourself you are willing to invest, the greater the return.

Furthermore, it is my policy to only see clients who I believe have the capacity to achieve their goals with my assistance.  It is my intention to empower you in your growth process to the degree that you are capable of facing life's challenges in the future without me.  I don't believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping you.  I may ask that as a part of our ongoing therapy process, other professionals such as a psychiatrist, medical doctor or dietician become part of the treatment team.  I may also suggest a higher level of care than I can provide.  If this is the case, I will direct you to these resources as your success, personal safety and development is my number one priority.

Confidentiality & Records

Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI).  Your PHI will be stored electronically and encrypted for safety.  Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you ask me to tell someone and you sign a "Release of Information" form; (2) I determine that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) I am ordered by a judge to disclose information. Privileged communication is your right as a client to have a confidential relationship with a therapist and I will do everything in my power to protect it but I cannot guarantee that I won't be compelled to reveal information should I lose an appeal to testify under a subpoena.   

Minors in Therapy, Confidentiality, and Records

I see clients 12 and above.  I can make a referral for clients under the age of 12.  If a client is under 18 years of age (the age of majority in Texas) the following applies:  A parent or legal guardian must accompany the client to the first appointment and sign the "Informed Consent to Therapy" on behalf of the client. If the adolescent is in the custody of a legal guardian, proof of guardianship must be presented before therapy is initiated. A stepparent may only consent to therapy if the stepparent has legally adopted the client and presents a copy of the adoption. If the client's parents are legally separated or divorced, a copy of the temporary orders or divorce decree indicating the custody agreement must be presented before therapy is initiated. This is waived if both parents are present for the first appointment and sign the "Informed Consent to Therapy". If the decree indicates both parents must agree to treatment, therapy will not be initiated unless both parents sign the "Informed Consent to Therapy". If the client has received a court-ordered emancipation decree a copy of the decree must be presented before therapy is initiated.  The therapist will retain in the client's file a copy of any legal document that is presented on behalf of the client. The parent(s) or legal guardian(s) of the client has the right and responsibility to ask questions about the therapy process, to understand the nature of activities with the client, and to be informed of the client's progress. Sessions with one or more parents or guardians are often scheduled for this purpose with the consent and participation of the adolescent.

Clients under the age of 18 years who are not emancipated and their parents should be aware that the law allows parents to examine their child's treatment records unless I believe that doing so would cause harm.  Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up their access to their child's records.  If they agree, during treatment I will provide them only with general information about the progress of treatment.  If I feel that the adolescent is in danger or is a danger to someone else, I will notify the parents of my concern. 

When a family is confronted by parental separation or divorce, it is very hard on everyone.  It can be particularly hard on adolescents, as this is a tumultuous time for them anyway. It is very important that therapy presents a safe environment for a teenager.  That safety is endangered when a teen has to worry that what he or she says will be revealed in court and used against one of his/her parents.  In order to protect that safety, I want us all to agree that the therapist will not be called as a witness by either parent to court.  Everyone needs to understand that a judge may decide not to honor this agreement and that I may be required to be a witness, although I will try to prevent that from happening.  Once we start treatment it is unethical of me to give any opinion about custody or visitation arrangements, even if I am compelled to be a witness, as this is not my area of expertise.  I will request your written permission to provide information to anyone who the court appoints to perform a custody evaluation or to represent the legal interests of your children. I will not make recommendations about that person however.   

Structure and Cost of Sessions

I agree to provide therapy for the fee of $100 per 50 minute session. I also charge this amount for other professional services you need, though I will break down the cost if I work for periods of less than 55/60 minutes.  Other services include report writing, telephone calls that exceed 10 minutes in duration, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any service you request of me.  The fee is requested at the conclusion of the session.  Please use your client portal to pay bills and print your receipts and superbills for insurance submission. Cash and personal checks made to Trauma Detox are also acceptable for payment. Please note that there is a $25 fee for any returned checks. 

Insurance companies have many rules and requirements specific to certain plans. It is your responsibility to find out your insurance company's policies and to file for insurance reimbursement.  I will be glad to provide you with a statement for your insurance company and to assist you with any questions you may have in this area.  I file insurance forms directly for a limited amount of companies.  Please be aware that I am an out-of-network provider for all remaining insurance companies.

If you become involved in legal proceedings that require my professional participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Court testimony or deposition requires a subpoena and advanced payment of fees. These fees include local travel expenses and meals. All fees must be paid no later than 72-hours (3 business days) in advance of the deposition or court appearance. In the event the deposition or court appearance is cancelled, the client forfeits all advanced fees unless the office receives a cancellation notice by phone at least 72-hours (3 business days M-F) prior to the scheduled event.

Cancellation Policy

In the event that you are unable to keep an appointment, please cancel through the portal at least 24 hours in advance.  If such advance notice is not received, you will be financially responsible for the session you missed at the rate of $80.  Please note that insurance companies do not reimburse for missed sessions.  If you have a true emergency please let me know.

In Case of an Emergency

My practice is considered to be an outpatient facility, and I am set up to accommodate individuals who are reasonably safe and resourceful.  I do not carry a beeper nor am I available at all times.  I will read shared journals through the client portal and comment from time to time between our sessions.   If via the portal it seems that you need more support I may ask you to schedule a 15 minute chat session, which is billable.  If at any time this does not feel like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a facility that provides a higher level of care. Generally, I will return phone calls or portal messages within 24-48 hours.  If you have a mental health emergency, I encourage you not to wait for a return call, but to do one or more of the following:

     Call the nearest Behavioral Health Hospital:

(Georgetown Behavioral Health Institute: 877-500-9151; Rock Springs Hospital 512-746-7163)

     Call Williamson County Mobile Outreach Team,1-800-841-1255

     Call 911.

     Call crisis suicide hotline at 1-800-273-8255, press 1 if you are a military veteran.

     Use Veteran crisis chat via your phone by texting 838255, and a therapist will answer you.

     Go to your nearest emergency room.

Professional Relationship

Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, your relationship with me has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed.  It must also be limited to only the relationship of therapist and client.  If you and I were to interact in any other ways, such as meeting for coffee or giving each other gifts, we would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical. This is why your relationship with me must remain professional in nature.

A therapist is not like a friend, in that they offer you choices and help you choose what is best for you. A therapist helps you learn how to solve problems and make better decisions based on tested theories and methods of change.  Therapists are required to keep the identity of their clients confidential and as such I will not address you in public unless you speak to me first. When your therapy is completed, I will not be able to be a friend to you like your other friends. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.

Statement Regarding Ethics, Client Welfare & Safety

I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the Texas State Board of Licensed Professional Counselors. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately.  If we are unable to resolve your concern, I will provide you with information to contact the professional licensing board that governs my profession.

Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so.  However, with your participation, we will work to achieve the best possible results for you.  Please also be aware that changes made in therapy may affect other people in your life.  For example, others who don't want a change may not always welcome an increase in your speaking up for your wants and needs.  It is my intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility as therapy if very often about change.

Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better.  This may occur as you begin discussing certain sensitive areas of your life, such as trauma, which you have quite possibly been referred to me for.  However, a topic usually isn't sensitive unless it needs attention, and then when it does, it is painful. Discovering the discomfort is actually a success.  Once we are able to target your treatment needs and the ways to address them that work best for you, pain often loses its power over you.

Technology Statement

In our ever-changing technological society, there are several ways we could potentially communicate electronically.  It is of utmost importance to me that I maintain your confidentiality, respect your boundaries, and ascertain that your relationship with me remains therapeutic and professional.  Therefore, I've developed the following policies:

Cell phones:  It is important for you to know that cell phones may not be completely secure and confidential.  However, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you.  If this is a problem, please feel free to discuss this with me.  I do not provide my cell phone number but all calls and texts to the practice number on the website come directly to me and only me.

Text Messaging and Email:  Both text messaging and emailing are not secure means of communication and may compromise your confidentiality.  However, I realize that many people prefer to text and/or email because it is a quick way to convey information.  Please feel free to email or text me.  However, please know that it is my policy to utilize these means of communication strictly for brief topics.  Please do not bring up any therapeutic content via text or email to prevent compromising your confidentiality.  The client portal provides a safe and secure way to communicate with me via your shared journal entries and messages.  You also need to know that I am required to keep a copy of all emails and texts as part of your clinical record. 

Facebook, LinkedIn, Instagram, Pinterest, Etc:  It is my policy not to accept requests from any current or former client on social networking sites such as Facebook, LinkedIn, Instagram, Pinterest, etc. because it may compromise your confidentiality.

Google, etc.:  It is my policy not to search for my clients on Google or any other search engine.  I respect your privacy and make it a policy to allow you to share information about yourself with me as you feel appropriate.  If there is content on the Internet that you would like to share with me for therapeutic reasons, please print this material out and bring it to your session.

Faxing Medical Records:

If you authorize me (in writing) via a "Release of Information" form to send your medical records or any form of protected health information to another entity for any reason, I may need to fax that information to the authorized entity. It is my responsibility to let you know that fax machines may not be a secure form of transmitting information even though using a secure faxing company like SFAX.

Recommendations to Websites or Applications (Apps):

During the course of our treatment, I may recommend that you visit certain websites for pertinent information or self-help. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites/apps, may be able to see that you have been to these sites by viewing the history on your device. Please let me know if you prefer that I do not make these recommendations.

In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time.  Please feel free to ask questions, and know that I am open to any feelings or thoughts you have about these and other modalities of communication.

PLEASE continue to final page, print and sign it, and bring it to your first appointment.

T

Trauma detox

Danielle west

3617 Williams Drive Suite 1006

Georgetown texas 78626

Our Agreement to Enter into a Therapeutic Relationship

I am sincerely looking forward to facilitating you on your journey toward healing and growth.  If you have any questions about any part of this document, please ask. 

Please print this final page, date, and sign your name below indicating that you have read and understand the contents of this "Information, Authorization and Consent to Treatment" form as well as the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices" provided to you separately. Bring both signature pages to your first appointment.  Your signature indicates that you agree to the policies of your relationship with me, you do consent, and you are authorizing me to begin treatment with you.  Adults and adolescents sign below:

__________________________________________________         

                        Client Name (Please Print)                               

__________________________________________________  Date________                

                                 Client Signature                                             

If Applicable:

__________________________________________________                

        Parent's or Legal Guardian's Name (Please Print)                                                                    

__________________________________________________   Date_________          

        Parent's or Legal Guardian's Signature                         

My signature below indicates that I have discussed this form with you and have answered any questions you have regarding this information.

__________________________________________________   Date_________                                        

                          Danielle West MA LPC