IMPORTANT INFORMATION AND CLIENT CONSENT: The following Consent Form is signed by all clients prior to therapy. Refer here if you have questions.
CLIENT/THERAPIST RELATIONSHIP: You and I have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when I focus solely on therapy and avoid any type of social or business relationship. Gifts are not appropriate, nor is any sort of trade of service for service. If we see each other in public, I will not acknowledge you to honor confidentiality. If you wish to talk to me, know that you are potentially exposing your use of my services. I do not accept any invitations to social media, such as FaceBook, Twitter, etc. to honor confidentiality of you and me.
AVAILABLE SERVICES: Melissa’s Counseling & Coaching offers a wide array of counseling and coaching services, including individual, couples, and group services. Melissa is a skilled and experienced licensed professional counselor and coach. Effective psychotherapy is founded on mutual understanding and good rapport between client and therapist. It is my intent to convey the policies and procedures used in my practice, and I will be pleased to discuss any questions or concerns you may have.
RISKS AND BENEFITS: Counseling, psychotherapy and coaching are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues, which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. I cannot guarantee these benefits, of course. It is my desire, however, to work with you to attain your personal goals for counseling, psychotherapy and/or coaching.
COUNSELING: I provide counseling designed to address many of the issues my clients are dealing with. Your first paid visit will be an assessment session in which you and I will determine our fit with each other. If we both still agree that Melissa Counseling & Coaching can meet your therapeutic needs, we will go forward with counseling.
The goal of Melissa’s Counseling & Coaching is to provide the most effective therapeutic experience available to you. If at any time you feel that you and I are not a good fit, please discuss this matter with me to determine if transferring to a more suitable therapist is right for you. If you and I decide that other services would be more appropriate, I will assist you in finding a provider to meet your needs. If you feel I have violated any laws, you may file a formal complaint with:
Complaints Management and Investigative Section
P.O. Box 141369
Austin, TX 78714-1369
Wellness is more than the absence of disease; it is a state of optimal well-being. It goes beyond the curing of illness to achieving health. Through the ongoing integration of our physical, emotional, mental, and spiritual self, each person has the opportunity to create and preserve a whole and happy life. My services are designed to provide you an integrated solution for your mind, body, spirit, and life to enhance your life and resolve issues.
APPOINTMENTS: Appointments are typically scheduled on a weekly basis and are approximately 50 minutes long. If you must cancel or reschedule your appointment, I ask that you call my office at 512-381-0833 at least 24 hours in advance, whenever possible. This will free your appointment time for another client. If it is not an emergency and you do not provide 24-hours notice, you will be charged for the appointment.
PAYMENT/INSURANCE FILING: Payment of fees is expected at the time of each appointment. Cash or check is accepted. All checks are made payable to Melissa Quiter. As insurance is not accepted, I will provide you with a statement/receipt of services if you wish to file your own claim. Credit/Debit and PayPal are available online as a pre-payment option.
EMERGENCIES: You may encounter a personal emergency, which will require prompt attention. In this event, please contact my office regarding the nature and urgency of the circumstances. I will make every attempt to schedule you as soon as possible or to offer other options. Because clients may be scheduled back-to-back, it is not always possible to return a call immediately. However, I will make every effort to respond to your emergency in a timely manner. If your emergency arises after hours or on a weekend, you should call 9-1-1 or have someone take you to the nearest emergency room for help. On average, I answer calls/emails within 24-hours (unless out of the office, which I document in a phone message or email autoreply).
CONFIDENTIALITY: Melissa’s Counseling & Coaching follows all ethical standards prescribed by state and federal law. I am required by practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to you.
Discussions between a Therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include, but are not limited to, the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the Therapist has a duty to disclose, or where, in the Therapist’s judgment, it is necessary to warn or disclose; fee disputes between the Therapist and the client; a negligence suit brought by the client against the Therapist; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to the attention of the Therapist when you and the Therapist discuss this matter further. By signing this Information and Consent Form, you are giving consent to the undersigned Therapist to share confidential information with all persons mandated by law and you are also releasing and holding harmless the undersigned Therapist from any departure from your right of confidentiality that may result. If you choose to use any electronic communication, there is always the risk of security breaches.
If you become involved in legal proceedings and need to request information from me, I will charge my usual rate of $100.00 per hour. This fee will cover services provided in preparing reports, handling relevant telephone conversations, preparing records, traveling to and from court, waiting to testify, and actually testifying in court. The charge for duplicating records is $0.10 per page for standard-size paper copies.
DUTY TO WARN/DUTY TO PROTECT: If my Therapist believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to my Therapist to contact the any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger.
INCAPACITY OR DEATH: I understand that, in the event of the death or incapacitation of the undersigned Therapist, it will be necessary to assign my case to another Therapist and for that Therapist to have possession of my treatment records. By my signature on this form, I hereby consent to another licensed mental health professional, selected by the undersigned Therapist, to take possession of my records and provide me copies at my request, and/or to deliver those records to another therapist of my choosing.
Cash or check is accepted in the office at the time of your appointment.