As with any treatment, there are some risks as well as many benefits with therapy. You should think
about both the benefits and risks when making any treatment decisions. For example, in therapy, there is
a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration,
loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These
feelings or memories may bother a client at work or in school. In addition, some people in your
community may mistakenly view anyone in therapy as weak, or perhaps as seriously disturbed. Also,
clients in therapy may have problems with people important to them. Family secrets may be told.
Therapy may disrupt a marital relationship. Sometimes, too, a client’s problems may temporarily worsen
after the beginning of treatment. Most of these risks are to be expected when people are making
important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not
work out well for you.
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.
Your therapist will treat with great care all the information you share with her. It is your legal right that
your sessions and the records about you be kept private. That is why we ask you to sign a
“release-of-records” form before anyone can talk about you or send any records about you to anyone
else. In general, your therapist will tell no one what you tell her/him. They will not even reveal that you
are receiving treatment. In all but a few rare situations, your confidentiality (that is, your privacy) is
protected by state law and by the rules of our profession. The details are outlined on the HIPAA notice
of Privacy Practices that you have received.
There are two situations in which your therapist might talk about part of your case with another
therapist. First, when your therapist is away from the office for a few days, another therapist in the
practice would be made available for emergencies. Second, our therapists sometimes consult other
therapists or other professionals about our clients. This helps 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 your therapist must
discontinue your relationship because of illness, disability, or other presently unforeseen circumstances,
your therapist will ask you to agree to transfer your records to another therapist at our practice who will
assure their confidentiality, preservation, and appropriate access.
There is an exception to confidentiality because of the family nature of the therapy we provide. Your
therapist will not keep family secrets from family members as we think that secrets are often at the root
of family problems. Your therapist will also not go behind your back. Instead, if you reveal something
to your therapist that she/he feels would be something important to share with your family members
she/he will talk to you about it and encourage you to disclose that information yourself, or even help you
in that disclosure.
If you could benefit from a treatment we cannot provide, we will help you to get it. You have a right to
ask about such other treatments, their risks, and their benefits. Based on what we learn about your
problems, we may recommend a medical exam or use of medication. If we do this, your therapist will
fully discuss the reasons with you, so that you can decide what is best. If you are treated by another
professional, we will coordinate my services with them and with your own medical doctor.
If for some reason treatment is not going well, we might suggest you see another therapist or another
professional in addition to your therapist. As a responsible person and ethical therapist, we cannot
continue to treat you if the treatment is not working for you. If you wish for another professional’s
opinion at any time, or wish to talk with another therapist, we will help you find a qualified person and
will provide him or her with the information needed.
In our ever-changing technological society, there are several ways we could potentially communicate
and/or follow each other electronically. It is of utmost importance to us that we maintain your
confidentiality, respect your boundaries, and ascertain that your relationship with your therapist remains
therapeutic and professional. Therefore, we’ve developed the following policies-
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.
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.
In summary, technology is constantly changing, and there are implications to all of the above that your
therapist may not realize at this time. Please feel free to ask questions, and know that she is open to any
feelings or thoughts you have about these and other modalities of communication.
The very first time you meet with your therapist, you will need to give each other mostly basic
information. Therapy will usually start with a session once a week, then less often. We will reserve a
regular appointment time for you into the foreseeable future. We also do this for our other patients.
Therefore, we are rarely able to fill a canceled session unless we have several days’ notice.
You will be charged the full fee for sessions canceled with less than 24 hours’ notice, for other than
the most serious reasons. Insurance will not cover this charge.
Please refer to the pricing sheet provided for you.
Payment should be made when services are rendered. If you think you may have trouble paying your
bills on time, please discuss this with your therapist. If you get behind more than the cost of two
sessions, you will be notified in writing. If it then remains unpaid, we 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 your charges, your billing, your insurance, or any other money-related
point, please bring it to our attention. We will do the same with you. Such problems can interfere
greatly with our work. They must be worked out openly and quickly.
Your therapist cannot promise to be available at all times. We do not take phone calls when we are with
a client. You can always leave a message on the confidential voicemail, and we will return your call as
soon as we can. Generally, we will return messages daily except on weekends and holidays.
If you have a behavioral or emotional crisis and cannot reach the office, 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).
It is our intention to fully abide by all the rules of the Georgia Composite Board of Professional
Counselors, Marriage and Family Therapist and Social Workers. Problems can arise in our relationship,
just as in any other relationship. If you are not satisfied with any area of our work, please raise your
concerns with us at once. We will make every effort to hear any complaints you have and to seek
solutions to them. If you feel that your therapist, or any other therapist, has treated you unfairly or has
even broken a professional rule, please tell one of us at the practice. You can also contact the Georgia
Secretary of State. A representative can help clarify your concerns or tell you how to file a complaint.
In our practice at Building Blocks Family Counseling, we 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. We 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 our attention immediately.
Telemental health is live two - way audio and video electronic communications that allows therapists
and clients to meet outside of a physical office setting.
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.
All fees that may apply during your treatment with our practice are listed below. All provider fees
reflected below are self pay rates. If you utilize insurance for your appointments, the fee per session will
vary based on your individualized insurance policy benefits.
Doctoral Level Licensed Providers - $150 per
Master Level Licensed Providers - $120 per session
Associate Level Unlicensed Providers
(Supervised) - $60 per session
Intern Providers (Supervised) - $30 per session
No Show Fee - Subject to the full fee of the session
Late Cancellation - Subject to half the fee of the session
Court/Documentation Fees - Court appearance - Session Rate x length (time) of appearance (minimum). Documentation - varies based on need. Please see below for exclusions/additions.
The fees outlined below are not covered by insurance and would be charged to you directly.
A No Show is considered to be an appointment that was scheduled and your therapist is not notified that
you need to reschedule/cancel or an appointment that was scheduled that was not attended by the client.
Each session has a 15 minute grace period following the start of the appointment to reach out to your
therapist in case of emergency to notify them of the need to reschedule. Please call or text your
therapist’s direct line in the case of an emergency or last minute cancellation. If there is no
communication with your therapist before the 15 minute grace period then the appointment will be
automatically counted as a no show and you will need to contact your therapist directly to reschedule.
Please note that each session is scheduled in a 60 minute time slot so you will only receive the
designated time left in your appointment.
A Late Cancellation is considered to be an appointment that is canceled or asked to be rescheduled
within 24 hours of the scheduled appointment.
Please make every effort to communicate with your therapist (directly) when needing to cancel or
reschedule appointments. If late cancellations or repeated missed appointments become an issue,
Building Blocks reserves the right to adjust appointment times as needed.
Court/Documentation Fees vary depending on multiple factors such as: time frame, form of
documentation requested, and in person/virtual attendance or the location of appearance requested. Due
to the variation you must discuss these directly with your therapist. Court appearances and
documentation are required to be requested with a minimum of a 48 hour notice prior to needing
the documentation or appearance. An additional fee may be applied in excess of the minimum rate for
Building Blocks reserves the right to space out appointments or pause services to collect unpaid
fees when a payment plan is not in place.
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.