WELCOME and thank you for requesting my services. After over twenty years as a professional mental health counselor, I continue to devote my life to guiding others to experience greater joy and personal success. Like many of us, a personal crisis at a formative age had a tremendous impact on my personal development, which led me to have a deep desire and commitment to become a therapist. As a result of this calling, I am honored to have the opportunity to be a part of the healing and change process of others as a therapist. After graduating from the University of Florida with my master’s and a Specialist degree in mental health counseling in 1992, I trained an additional three years as a Marriage and Family Therapist and I continue to train in specific treatment modalities each year. Please read this document carefully. When you sign this document, it will represent an agreement between us.
Engaging in counseling can take a great deal of courage and commitment and it can produce meaningful and worthwhile benefits in your life. I encourage you to talk to me as honestly as possible about the issues that are concerning you and your life history since this will guide treatment. Counseling is most successful when you actively work on the things that you discuss with me, your therapist, both during your sessions and in your life. Counseling often leads to better relationships, solutions to specific problems, and significant reductions in feelings. On the other hand, counseling can also have risks. Since therapy often involves working through challenging or unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. It is important for you to keep me informed if what you are talking about in counseling is causing exceedingly uncomfortable or distressing feelings. I ask that if you are thinking about stopping treatment, or if you feel I am not providing what you need, that you discuss this with me. Perhaps we can discuss a different approach or a referral to another therapist if you do not feel I am the right “fit” for you.
STATEMENT OF CONFIDENTIALITY- Your sessions and your records are confidential except as outlined in the HIPAA agreement and as limited by law. No information is provided to anyone outside this office without written consent. Please be aware that when you are receiving couple’s or family therapy the record belongs to all of you. Hence, information regarding the therapy can only be released if signed by all adult parties involved in the therapy. There are some exceptions to the confidentiality statement where disclosure is required by law. These are some of the circumstances that may require disclosure of your records or communication with me your therapist:
If you reveal information to your counselor about child abuse/neglect or elder abuse, your counselor is required by law to report this to the appropriate authority. This includes situations where violence occurs between two adults while children are in the home. Any reasonable suspicion of these matters may also be reportable.
If you indicate that you have a plan, the means, or make credible threats to harm yourself or someone else, your counselor is required by law to notify potential helpers which may include law enforcement agencies, in order to provide you with a safe place where no harm can come to you. This can be done voluntarily which is ideal or if the threat is serious and of concern, an involuntary action may be taken.
If you are participating in counseling due to a Judge’s court order, the counselor’s professional opinion must be provided to that court upon request.
If a court of law issues a court order, I am required by law to provide the information.
If you have a Guardian Ad Litem involved with one of your children, typically due to an open DCF case, they are allowed by law to have access to your records. Even though this is rare, you need to be aware of this possibility.
If you are a minor, your parents must consent to treatment, but you have the right to having a confidential therapy with me. The exception is if you are engaging in serious self or other harming activity, in which case, I may need to disclose that information to your caregivers to ensure safety.
If you are receiving couple’s or marital counseling, the case file belongs to both of you and I cannot release any information unless both of you agree, in writing and sign a release form. Hence, you do not have rights to your record as an individual when you receive couple’s counseling.
Because of the great expense incurred when a client no shows, cancels without 24-hour notice or a therapist becomes involved on a court case, I must charge for my time for these events. By signing this form you agree that if you no show, or fail to give me a 24 hour notice when you cancel your appt. a no- show fee of $50 will be charged to you on the first event and full fee on the second missed appointment and thereafter. Also, should I be called to court for any reason related to a case you may be involved in, by signing this, you agree to pay me $150 per hour, including time I have spent preparing for court and engaged in court activities on your behalf or related to a legal situation in which you may be involved in the future. Finally, if your insurance company does not pay for your treatment, you agree to pay the fees for this service and I am forced to seek legal help due to non-payment, you agree to pay the legal fees that I incurred plus an additional $75 per hour of my time for preparing to recuperate those fees and costs. Although I have never had to resort to this, it is important for you to understand your responsibilities as a client.
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i acknowledge that I have been offered a copy of this and the HIPAA Florida Notice Form for my own records via the FORMS section on my website, right below this form. If you provide your email address, or cell number to me, I will consider this as your permission to communicate with you in this manner unless you let me know otherwise. I also acknowledge that if I am participating in video counseling sessions, there is a risk of less confidentiality associated with the use of this technology and in participating I accept this risk and will not hold Theresa Rodriguez liable. In addition, if I am choosing to use my health insurance or my Employee Assistance Program, I authorize the transmittal of information via email and electronic systems for billing purposes. I also, understand that insurance companies and Employee Assistance Programs, sometimes require therapists to provide some information regarding services such as discharge status information, diagnosis codes if billed to insurance (EAP’s do not require a diagnosis) and communication with a case manager if there is a crisis that is potentially harmful to self or others. PsychResources, (aka ComPsych) EAP, requires at discharge, the general reason you received counseling such as “relationship issues”, “occupational issues”, “stress”, “substance abuse”, “trauma”, “domestic violence” and others. I also understand that a diagnosis is required if billing insurance that denotes mental health distress such as anxiety, depression, bipolar Dx etc. Please discuss this with Ms. Rodriguez if you have further questions or concerns.
