Starting November 21st our Savannah office will no longer be located on Congress Street .
We're moving to 3025 Bull Street, Savannah, GA 31405 Unit 219.
While you consider these risks, you should also know that the benefits of therapy have been shown by
scientists in hundreds of well-designed research studies. People who are depressed may find their mood
lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk
things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and
coping skills may improve greatly. They may get more satisfaction out of social and family
relationships. Their personal goals and values may become clearer. They may grow in many
directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy
their lives. Your therapist does not take on clients they do not think they can help. Therefore, your
therapist will enter your relationship with optimism about your progress.
There are two situations in which I might talk about part of your case with another therapist. I ask now
for your understanding and agreement to let me do so in these two situations. First, when I am away
from the office for a few days, I have a trusted fellow therapist “cover” for me. This therapist will be
available to you in emergencies. Of course, this therapist is bound by the same laws and rules as I am to
protect your confidentiality. Second, I sometimes consult other therapists or other professionals about
my clients. This helps me in giving high-quality treatment. These persons are also required to keep
your information private.
Your name will never be given to them, and they will be told only as much as they need to know to
understand your situation. If I must discontinue our relationship because of illness, disability, or other
presently unforeseen circumstances, I ask you to agree to my transferring your records to another
therapist who will assure their confidentiality, preservation, and appropriate access. There is an
exception to confidentiality because of the family nature of the therapy I provide. I do not keep family
secrets from family members as I think that secrets are often at the root of family problems. I also will
not go behind your back. Instead, if you reveal something to me that I feel would be something
important to share with your family members I will talk to you about it and encourage you to disclose
that information yourself, or even help you in that disclosure.
If for some reason treatment is not going well, I might suggest you see another therapist or another
professional in addition to me. As a responsible person and ethical therapist, I cannot continue to treat
you if my treatment is not working for you. If you wish for another professional’s opinion at any time,
or wish to talk with another therapist, I will help you find a qualified person and will provide him or her
with the information needed.
Video Monitoring and Recording: There may come a point in treatment when your therapist may
request to video record/film sessions. Prior to filming, your therapist will discuss the terms and
agreements as well as having a separate consent form signed. The client always has the option to not
Cell Phones: It is important for you to know that cell phones may not be completely secure and
confidential. However, we realize that most people have and utilize a cell phone. Your therapist may also
use a cell phone to contact you. If this is a problem, please feel free to discuss this with her. Out of
respect for yourself and the therapeutic process, your therapist does ask that all clients silence their
phones and do their best not to respond to messages or take calls during therapy.
Text Messaging and Email: Both text messaging and emailing are not secure means of communication
and may compromise your confidentiality. However, we realize that many people prefer to text and/or
email because it is a quick way to convey information. Please note that your therapist does not accept or send texts as a way of communication with the exception to remind of appointments. Appointment
reminders via text and email are sent from an automated system that you will not be able to respond to.
Email will not be used for crisis situations or as a substitute for therapy. We ask that email only be used
for brief matters of communications that can allow for a 24-48 hour response time. You also need to
know that we are required to keep a copy of all emails and other electronic communications as part of
your clinical record. If you find the need to communicate frequently with your therapist between
sessions, it may be that you need to schedule more frequent visits. You are encouraged to protect your
own confidentiality by controlling access to your communications with your therapist such as by using
passwords only known by you, controlling access to your computer, etc. Please discuss with your
therapist the preferred way for communicating outside of session.
Facebook, LinkedIn, Instagram, Pinterest Etc: It is your therapist's policy not to accept requests from
any current or former clients on social networking sites such as Facebook, LinkedIn, Instagram,
Pinterest, etc. because it may compromise your confidentiality. You may “like” the Building Blocks
Family Counseling Facebook page as this is a community page where upcoming events and helpful
information are shared. We also encourage all clients to sign up to receive the Building Blocks weekly
newsletter which is filled with blog posts, helpful tips, and upcoming events.
I will reserve a regular appointment time for you into the foreseeable future. I also do this for my other
patients. Therefore, I am rarely able to fill a cancelled session unless I have several days’ notice.
I accept debit and credit cards, health savings account, cash, or check. Those with insurance coverage
are expected to pay the co-payment or co-insurance at the time of service. If your insurance coverage is
rejected, then you will be responsible for the full fee. You should call your insurance company to verify
benefits, determine co-pay amounts, and get information on deductibles, prior authorization or the need
for a doctor’s referral.
Payment should be made when services are rendered. If you think you may have trouble paying your
bills on time, please discuss this with me. If you get behind more than the cost of two sessions, I will
notify you in writing. If it then remains unpaid, I must stop therapy with you. Fees that continue unpaid
after this will be turned over to small-claims court or a collection service.
If there is any problem with my charges, my billing, your insurance, or any other money-related point,
please bring it to my attention. I will do the same with you. Such problems can interfere greatly with
our work. They must be worked out openly and quickly.
If you have a behavioral or emotional crisis and cannot reach me, you or your family members should
call the Georgia Crisis and Access Line at (800) 715-4225, or go to the nearest hospital emergency room
(or dial 911).
In my practice as a therapist, I do not discriminate against clients because of any of these factors: age,
sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status,
physical disability, health status, sexual orientation, or criminal record unrelated to present
dangerousness. I will always take steps to advance and support the values of equal opportunity, human
dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please
bring this matter to my attention immediately.
I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My
signature below indicates that I have read and discussed this agreement; it does not indicate that I am
waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist,
before I start (or the client starts) formal therapy. I also understand that any of the points mentioned
above can be discussed and may be open to change. If at any time during the treatment I have questions
about any of the subjects discussed in this handout, I can talk with you about them, and you will do your
best to answer them.
I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for
any reason. However, I will make every effort to discuss my concerns about my progress with you
before ending therapy with you.
I understand that no specific promises have been made to me by this therapist about the results of
treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary
for therapy to be effective.
I have read, or have had read to me, the issues and points in this handout. I have discussed those points I
did not understand, and have had my questions, if any, fully answered. I agree to act according to the
points covered in this brochure. I hereby agree to enter into therapy with this therapist (or to have the
client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here.
My signature below also indicates that I have been given a copy of the HIPAA Notice of Privacy
Practices. My signature authorizes the release of information necessary to process health insurance
claims and authorizes the payment of health benefits directly to the provider (if applicable).
I understand that I have certain rights to privacy regarding my protected health information. These rights are
given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand
that by signing this consent I authorize you to use and disclose my protected health information to carry out:
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy
Practices, which contains a more complete description of the uses and disclosures of my protected health
information and my rights under HIPAA. I understand that you reserve the right to change the terms of this
notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that my therapist will be billing me for therapy, evaluation services and or any other
covered services. I further understand that I am responsible for all my fees as well as late cancellations
or no-show charges.
I also understand that some services are not covered under insurance or that I have the option to not use
my insurance. In either of these cases I agree to pay the full session fee as determined by my provider. I
understand that fees are due at the time services are rendered and must be paid in full unless a payment
plan has been agreed to by my provider.
I hereby acknowledge that I understand and give my therapist permission to charge my credit card for
any services that have not been paid by myself. I understand that this form is valid for three years unless
I cancel the authorization in writing. If I cannot provide a credit card to place on file then I agree to
allow my therapist to release my demographic information to a collection agency for reimbursement if
payment or balance has been outstanding for a minimum of 120 days.
If parents are divorced, our office needs a copy of the most recent court order showing primary custody
or tiebreaker, or the consent of both parents.
Divorce, Separation, and Custody Agreements
Building Blocks Family Counseling will not be party to custodial, separation, or financial disputes relating to individuals with regard to minor children to whom services are provided. The individual who requests the counseling services and signs the financial agreement is responsible for any balance due. All co-pays, co-insurance, and deductible, if applicable, will be collected at the time services are rendered from the individual requesting the counseling services for the minor child/children. We expect consent from both parents for therapy services. The therapist will discuss the minor’s
therapeutic information with the accompanied parent with the time of the visit. Building Blocks Family Counseling will provide a copy of any records requested, all though we reserve the right to charge a fee. Both parents have access to the minor child’s records, unless there is a court order that specifically mandates only one of the parents has the right to authorize treatment and release of the minor’s records.