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AGREEMENT OF CONFIDENTIALITY
Confidentiality is significant in a therapeutic relationship. Everything that you relate to me in the context of a therapy session is confidential, except where the limits to confidentiality have been noted below.
In addition, your file that contains the information that you give me, will be kept in a locked filing cabinet, in a locked room. You are entitled to have a copy of your file notes or to read your file notes during your scheduled session. Your records will be destroyed 10 years after your file is closed.
It is important that you are aware of my limitations to confidentiality:
· As mandated by law, reporting of child abuse (sexual, physical, emotional / verbal).
· As mandated by law, reporting of clear and immediate danger to someone else (homicide); and as mandated by my code of ethics, reporting of immediate danger to oneself (suicide).
· Court orders or legal proceedings where I am a defendant in a civil, or criminal case arising from the therapy.
· Where a waiver is obtained from you, in writing, granting me permission to share information.
· When sharing general non-identifying information during consultation with another professional.
My commitment to you, along with confidentiality, is to ensure your safety and the safety of others.
I am aware that Tamara Monell will keep the information that I tell her confidential, except where the limitations to confidentiality have been noted. I understand and agree to the terms of the agreement as outlined here.
Client Waiver
I acknowledge the limitations inherent in ensuring the confidentiality of information transmitted through on-line counseling and also acknowledge the limitations that are inherent in a counseling process that is not provided face-to-face.
Electronic Transfers of Client information
I acknowledge that Mental health counselors that electronically transfer client confidential information to authorized third-party recipients only when both the professional counselor and the authorized recipient have "secure" transfer and acceptance communication capabilities; the recipient is able to effectively protect the confidentiality of the client's confidential information to be transferred; and the informed written consent of the client, acknowledging the limits of confidentiality, has been obtained.
Establishing the On-Line Counseling RelationshipAppropriateness of On-line Counseling
I am aware that Tamara has developed an appropriate in-take procedure to help determine whether on-line counseling is appropriate to meet my needs. Tamara has warned me of on-line counseling services that may not be appropriate in certain situations and, to the extent possible, inform the me of specific limitations, potential risks, and/or potential benefits relevant to the my anticipated use of on-line counseling services. Tamara has also informed me of the intellectually, emotionally, and physically capable of using on-line counseling services, and of understanding the potential risks and/or limitations of such services. Counseling Plans
Tamara will develop an individual on-line counseling plan that is consistent with both individual circumstances and the limitations of on-line counseling. If Tamara has determined that on-line counseling is inappropriate for me, she has warned me that she will avoid entering into or immediately terminate the on-line counseling relationship and encourage the me to continue the counseling relationship through a traditional alternative method of counseling. Boundaries of Competence
I acknowledge that Tamara provides on-line counseling services only in practice areas within her expertise. I also acknowledge that Tamara Monell does not provide services to clients in states where doing so would violate local licensure laws or regulations.
Legal Considerations
Tamara Monell confirms that the provision of on-line services are not prohibited by or otherwise violate any applicable state or local statutes, rules, regulations or ordinances, codes of professional membership organizations and certifying boards, and/or codes of state licensing boards.
Consent and Service Agreement
Please review the Agreement and Consent form below.
Welcome to Tamara Monell’s on line therapy site. This service agreement is
necessary to initiate on line therapy.
As a client of Tamara Monell I understand that online therapy is technical in nature
and there may be problems with Internet connections which is a problem independent of
Tamara or myself. Internet availability may be limited or disrupted by things such as server
maintenance, upgrades or other problems (such as software or hardware malfunction)
or other unforeseen circumstances---like internet viruses (heaven forbid).
I agree that I must be at least 18 years of age to consent to services. If you are younger
than 18, your parent or guardian must contact Tamara and provide a written consent for
services.
I agree that currently I am not experiencing suicidal thoughts (serious active one’s that
you have the intention to act on).
I am not currently being abused or neglected by a parent or guardian. This situation
requires an immediate and personal response. If you are a child or teen or adult being
abused, please seek out help via your primary care provider, the local hospital, by
contacting 911 or contacting your local suicide or mental health hotline.
I agree that under certain circumstances, Tamara is legally bound to violate
confidentiality. Such cases involve instances of abuse, serious suicidal gestures or any
serious threat a client makes of a homicidal nature toward another individual.
Furthermore if you are involved in criminal activity, this too must be reported.
As a client, I understand that Tamara Monell is a Licensed Mental Health Counselor in
the state of Florida and is subject to the laws and regulations of the state of Florida.
She is also bound to follow the American Mental Health Counselors Association’s Code of Ethics. For a detailed description of this code please see
http://www.amhca.org/code/.
As a client I understand that the success of undergoing on line therapy is uncertain. It
depends on the client’s commitment, whether the interaction of client and therapist is a
good fit and whether the problem could legitimately be helped via e mail
correspondence. Some problems must be addressed live in an ongoing face to face
therapy.
Although great steps have been taken to ensure confidentiality of online therapy,
Tamara cannot guarantee the security of internet transmissions. I permanently agree to
release and indemnify Tamara Monell, LMHC from all suits, claims, and other
actions originating from psychotherapy provided through Tamara Monell.
FEES
I understand that the initial consultation is free and used for Tamara’s treatment planning for my services.
I agree that thereafter, I will be charged $20.00 for each subsequent e mail. Tamara promises to respond to my e mail within 24-48 hours, unless she is on vacation or sick leave. In that case, Tamara will post this information on the website.
If I am interested in paying on a monthly basis for Tamara's services, I can retain her services for $______ per month. If I pay this monthly flat fee I will receive no more than 30 e mails, 1 daily checkin phone call and at least 1 monthly session by e-mail, face to face or phone. I am aware that Tamara will respond to each individual email within a 24-48 hour time span. I can write to Tamara as needed for treatment.
By completing the intake information and initiating treatment, it is understood that I
have read, understand and agreed to the terms.
______________________________ __________________________
Name of Client(s) Client ID #
______________________________ ___________________________
Signature of Client (s) Date
______________________________ ___________________________
Signature of Therapist Date
