THE FORMS BELOW MUST BE PRINTED, SIGNED AND MAILED FOR OUR FILES.
YOUR ASSISTANCE IS APPRECIATED.
Each client is provided with an information sheet that covers essential information. Please understand that you are financially responsible for services rendered. No– shows and late cancellations may be charged. PLEASE NOTE: Appointments must be cancelled 24 hours prior to the appointment;. I f you have any questions, I would be happy to discuss them with you. –
Please sign below to indicate that you have received and read these notations.
This is to provide you with general information about the services I provide and the policies and procedures of this office. I am dually licensed as a Licensed Mental Health Counselor and a Licensed Marriage and Family Therapist with a Master’s Degree in Counseling. I have over twenty years of experience as a therapist for individuals, couples, family, and groups. In addition, I am certified nationally by the National Board of Certified Counselors and a clinical member of the American Association of Marriage and Family Therapists.
My belief is that psychotherapy is a cooperative effort with my client. Your ability to benefit from treatment is dependent upon your willingness to honestly discuss your thoughts, feelings, and behaviors and to examine how these may be contributing to your difficulties. This often entails asking you to carry out assignments or specific activities between sessions. At times, psychotherapy may be an uncomfortable process that will need to proceed at a pace that is comfortable and safe for you. If a medical concern is a part of the reason for seeking psychotherapy, please be aware that I am not a medical doctor. Although we may discuss your condition and your use of medical interventions (e.g., medication intake and pattern), my comments are not intended to replace the recommendations of your physician. To clarify any potential misunderstandings, please review with me anything that seems contradictory. Please know that you are always advised to follow your physician’s instructions until you discuss possible revisions with him or her.
You will notice that I do not accept calls while I am with clients. During those times, or when I am out of the office, messages can be left on my voice mail. I will return your call as soon as possible. If your call is urgent, please make note of that in your message. In addition, if you are calling about an emergency situation and I am not immediately available, please call the local crisis hotline (407-425-2624), go to the nearest emergency room, or call the police for immediate assistance. If I am out of town, or otherwise unavailable for an extended period of time, a colleague will speak or see you in case of an emergency. Please be aware that their charges may be different than my own.
Should you be unable to attend an appointment, you must notify me 24 hours in advance. If, I do not receive such notice, you will be responsible for the full charge. Of course, emergencies are taken into consideration. I am dedicated to maintaining the privacy of your personal health information as part of providing professional care. I am also required by law to keep your information private. The law is complicated, and a separate form is being provided to you outlining the limits of the law and your rights. Please sign below indicating that this information has been made available to you. In addition, in this present time of electronic communications, I wish to advise you that all communications – emails, texts, skype, telephone conversations, etc. are considered confidential to the degree possible. Total control does not exist beyond the limits of the therapist and the office which is secure. Should any communiqué be interrupted, or compromised, every effort will be made to reconnect, resolve and manage the sensitive material of therapy.
By my signature below I certify that I have read the above information and I consent to psychotherapeutic treatment and the financial, no show agreements mentioned on the information sheet. By my signature below I am certifying that I have received and been given an opportunity to read a copy of the Notice of Privacy Practices. These Privacy Practices are posted in the waiting room. I understand that if I have any questions regarding the Notice or my privacy rights I can contact Lisa A. Smith.
Signature ______________________________ __________________________Date____________
I hereby consent to engage in e-therapy, teletherapy with Lisa Smith. I understand that the same confidentiality regulations apply to this form of treatment as to traditional health records. I understand that there are risks and consequences from telemedicine. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner. Should an interruption of contact occur, please be aware that every effort will be made to contact you, via, email, phone call, even physical mail