Client Informed Consent

By agreeing to work with me you recognize that you are making the choice to be here. Making the choice to attend mental health therapy can sometimes be difficult. Attending mental health therapy should feel comfortable and safe. You have the right to end therapy at any time. This is your therapy and it is important that the therapeutic process fits you. This is your journey; I can be on this journey with you, to listen, provide feedback, suggest exercises and tools; ultimately this is the work you are doing for yourself.

I hold the right to suggest other mental health professionals, and/or therapies, that may benefit your mental health needs outside my skills and abilities. If I do not feel like I am a right therapeutic fit for you, I will communicate that with you, and provide references to therapists/agencies who might be a better fit. I hold the right to end the therapeutic relationship at any time (with references to other therapists/agencies) if/when there are inappropriate behaviors as defined by this therapist. Due to the nature of telehealth, you cannot be operating a vehicle (driving), be in a public location, and you need to be clothed at all times during sessions (unless special accommodations have been made and there is a signed agreement between you and the therapist).

Client Confidentiality

Client confidentiality protects private and personal information. Information shared in therapy is protected by law. Sessions will remain private between you and the therapist, unless otherwise requested in writing or mandated to report (outlined below). I will do my best to protect your sensitive information. However, there are circumstances when it is required for me to break confidentiality. These include:

• In the event of a medical emergency, I may give necessary information to medical personnel.
• If I am concerned you might harm and/or attempt to die by suicide, I will seek and notify appropriate supports.
• If I am concerned you might harm and/or kill someone else, I will contact proper individuals and authorities.
• If I hear of abuse towards children, elderly individuals, and/or other vulnerable individuals, I will contact the proper authorities.
• Court-ordered treatment that requires shared information.

I will do my best to communicate with you if there is probable cause to break therapist/client confidentiality. However, be fully aware reporting may happen without communication.

Hold Harmless Agreement

I’m Listening Counseling Services/Viola Schrantz LMHC states that I’m Listening Counseling Services/Viola Schrantz LMHC is not responsible for injuries and/or damages (to self and/or property) in relation to session appointments and/or anything related to therapy.

I’m Listening Counseling Services/Viola Schrantz has the right to break confidentiality (as outlined above) without communication to the client. Viola will not be held responsible for any emotional, and/or physical, distress this may cause.

I’m Listening Counseling Services/Viola Schrantz will not be held responsible for privacy breaches that may occur if the client requests communication via email; noting that email communication is not HIPAA compliant.

I’m Listening Counseling Services/Viola Schrantz has the right to practice evidence-based therapeutic modalities she deems appropriate. It is up to the client to communicate with Viola verbally, and/or in writing if you have issues with the way that therapy is going. Viola will not be held responsible for lack of communication from the client.

I’m Listening Counseling Services/Viola Schrantz has the right to refuse to fill out any paperwork/forms requested by other formal supports, and has the right to refuse to write a therapeutic support letter(s).

I’m Listening Counseling Services/Viola Schrantz will not be held responsible for any services and/or accommodations refused/denied after submission(s) of form and/or letter(s) this therapist has filled out and/or written.

I’m Listening Counseling Services/Viola Schrantz will not be held responsible for an out-of-session mental health crisis.

Scheduling issues happen (rescheduling, cancellations by the therapist), and we understand that it may cause an inconvenience, however I’m Listening Counseling Services/Viola Schrantz LMHC will not be held responsible for any inconveniences, and/or discomfort this may cause the client.

I’m Listening Counseling Services/Viola Schrantz will not be held responsible if the client’s insurance company denies reimbursement (partial and/or full amounts) for therapeutic services.

I’m Listening Counseling Services/Viola Schrantz will not be held responsible for billing errors regarding insurance or copays. If there is an insurance billing discrepancy, client will be responsible for communicating with their insurance provider, and ILCS’s insurance biller.

I’m Listening Counseling Services/Viola Schrantz will not be held responsible for client’s out of pocket charges if/when insurance is denied or not covering session(s). (see services and costs regarding responsibility for payment)

I’m Listening Counseling Services/Viola Schrantz will not be held responsible for late cancellation/no show fees, or financial stress of fees collected (see services and costs regarding responsibility for payment). I’m Listening Counseling Services/Viola Schrantz will not be held responsible for reminding and/or notifying clients of their session date/time, at/on the date/time session is either about to start, or has started. Keeping track of session dates, and times, as well showing up is the client’s responsibility. Missing a scheduled appointment is fully the client’s responsibility.