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Terms and Policy

Informed Consent

Counseling Center Informed Consent

Welcome to SAGU Counseling Center! Our staff looks forward to coming alongside you to assist with your counseling goals. This document provides information about my office policies as well as other important information for you to understand as part of your informed consent to treatment. This information is in addition to that detailed in the Notice of Privacy Practices. Please read them and if you have any questions, discuss them with your counselor. Your signature at the bottom of this form signifies that you have read, understand and agree to abide by these policies and consent to engage in Counseling Center.

Professional Disclosure Statement

   SAGU Counseling Center Mission Statement: The SAGU Counseling Center seeks to assist people in identifying and achieving healthy solutions for their emotional, behavioral, relational and spiritual challenges, as well as achieving their personal growth goals.  In keeping with the mission and purpose of Southwestern Assemblies of God University, counseling is provided from a biblical perspective that integrates Christian values with empirically based counseling theory, techniques, and interventions based on client needs/goals.   The Counseling Center provides counseling and support without regard to a client's ethnicity, gender, age, marital status or religious affiliation. 

Staff and Qualifications: The counseling center is staffed by Licensed Professional Counselors, a Licensed Marriage and Family Therapist, a Licensed Master of Social Work, and a Master's level pastoral counselor. On occasion, Master's Level Practicum students provide services under the supervision of the Counseling Center staff.  Introductory information regarding our staff is provided below.  Additional information regarding each counselor's qualifications and license numbers can be provided upon request.

Tim W. Myers, D.Min, LMFT

Rachael Swearingin, LMSW (Supervised by Lacie Todd, LCSW)

Sarai Honeycutt, M.S., LPC-Intern (Supervised by Dr. Robert Mapes, Ph.D., LPC-S)

Darren Daugherty, Ph.D., LPC

Cassie Wilson, M.S., LPC-Intern (Supervised by Randel Duncan, M.A., LPC-S)

Mark White,M.S., LPC-Intern (Supervised by Randel Duncan, M.A., LPC-S)

Lindsey Steger, Practicum Student (Supervised by Tim W. Myers, D.Min, LMFT)

Katherine Pitts, Practicum Student (Supervised by Tim W. Myers, D.Min, LMFT)


Counseling is a collaborative process between you and a therapist to work on areas of dissatisfaction in your life and assist you with life goals. For counseling to be most effective, it is important that you take an active role in the process. The Texas State Board of Examiners governs counseling activities for Professional Counselors for LPC's and the Texas State Board of Marriage and Family Therapists for LMFT's. We do not provide custody evaluation recommendations, medication or prescription recommendations, nor legal advice, as these activities do not fall within our scope of practice. Benefits and Risks of Therapy: Counseling is a process in which the client and therapist will discuss a myriad of issues, events, experiences and memories for the purpose of gaining insight and experiencing positive change in working towards the client's therapeutic goals.   Benefits of counseling typically include symptom relief, an enhanced sense of well-being, and an increased ability to cope with peer and family relationships and/or academic pressures. You may also gain a better understanding of yourself which will assist in your personal development.  However, while many individuals show great benefit from counseling, a client's experience, reactions and outcomes to the counseling process cannot be predicted or guaranteed. The counseling process is intentional in addressing problems that cause internal distress and relational issues. This often results in the client experiencing and confronting uncomfortable issues that may lead you to feel sadness, sorrow, anxiety, or pain. In addition, the counseling process sometimes leads to client's making changes and major decisions which do impact other relationships and circumstances involving family, friends or the workplace. These decisions are a legitimate outcome of the counseling experience as a result of an individual or couple evaluating many of their beliefs and values. Furthermore, symptoms may be intensified and the emotional experience may be too intense to deal with at this time, depending on a client's situation. Your therapist will be available to discuss any of your assumptions or possible negative side effects in our work together. It is important to be aware that the success of the therapeutic relationship between you and your therapist depends on a quality, collaborative effort.    Consumer Information/Complaints- An individual who wishes to file a complaint against a Licensed Professional Counselor may write to: Complaints Management and Investigative Section; P.O. Box 141369; Austin, Texas 78714-1369; or call 1-800- 942-5540 to request the appropriate form or obtain more information.

An individual who wishes to file a complaint against a Licensed Marriage and Family Therapist (LMFT) or a Licensed Marriage and Family Therapist Associate (LMFT Associate) may write to: Complaints Management and Investigative Section, P.O. Box 141369. Austin, Texas 78714-1369 or call 1-800-942-5540 to request the appropriate form or obtain more information.    

Office Policies

Counseling Setting: Counseling is conducted at the SAGU Counseling Center offices located at: Bridges Hall, First Floor, 1200 Sycamore Avenue, Waxahachie, Texas 75165.  

Appointments: Individual appointments are typically scheduled for 50-minute segments, but can be different based on recommendations from your counselor. Your appointment time is held exclusively for you. Please arrive on time as you use your own time when you are late.  Length of Therapy- The number of sessions depends on many factors and will be assessed and discussed with you. Therapy will be terminated when goals have been achieved and by mutual consent. An exit session, or termination interview will be conducted at the end of therapy. You have the right to terminate therapy at any time

Cancellations: A personal commitment is crucial to the success of counseling. Please keep all of your scheduled appointments.  However, if you find it necessary to cancel an appointment, please contact the office at 972.825.4721 as far in advance as possible so that we may provide your appointment time to another person. No shows? Confidentiality: The information you share will be held confidential. I will ask you to sign a release of information form before disclosing any information obtained from your sessions or in writing to any other person or agency, including family members. State law and the ethics of our profession protect your confidentiality, except in the following cases.

The legal exceptions to confidentiality include, but are not limited to, the following:

If you make a serious threat to harm yourself or another person, the law requires your counselor to try and protect you or that other person. This notification may include notifying the victim, notifying the police, or seeking appropriate hospitalization.

If I believe a child, elder, disabled person, or dependent adult has been or will be abused or neglected, I am legally required to report this to the authorities.

If you send a health insurance claim form to your insurance for reimbursement, it will have a mental health diagnosis label and will become part of your permanent medical record. This may be relevant in situations where your medical record is necessary such as, but not limited to, qualifying for insurance, such as life, health, or disability insurance. I may also be required to provide additional details about the nature of your sessions to support medical necessity.

In order to provide you with the best service, I may consult with other mental health professionals about your case without revealing your identity.

If you are working with a Licensed Professional Counselor Intern or Master's level practicum student, your therapist is required to discuss your case on a regularly scheduled basis with his/her Supervisor. The Supervisor is also required to maintain confidentiality.  Practicum students are supervised by the Director of Counseling Center.  LPC Intern supervisor information is listed with your counselor's qualifications within this informed consent. 

If any situation arises that necessitates disclosure of confidential information, your therapist will make every effort to fully discuss it with you before taking any action and will limit disclosure to what is necessary. If you are under 18, your parent or legal guardian(s) may have access to your records and may authorize release to other parties. If I run into you outside of the counseling office, I will protect your confidentiality and wait for you to acknowledge me should you choose to do so.

A counselor's notes and any other written information regarding your contact with the Counseling

Center never become part of your college record and are accessible only by Counseling Center

staff. Counseling files are maintained at the SAGU Counseling Center for 5 years after the student's

graduation or departure from school and then destroyed. With your written authorization, counseling information can be disclosed to a third party for the specific purpose stated in your authorization. However, there are

certain circumstances where the Counseling Center has the right to deny your request. 

You may request to review your counseling records by filing a written authorization with the Director of Counseling Center. Your request must be responded to within a reasonable period of time. If the Director and your counselor believe that review of these records would be detrimental to your health or well-being, the Counseling Center reserves the right to require that a member of the Counseling Center staff be present while you review the file in order to discuss or help interpret information contained in the file.

Electronic Transmission: I cannot ensure the confidentiality of any form of communication through electronic media. Personal content sent via email is not secure and can be potentially compromised.  Therefore, by signing this consent form, you are acknowledging that the Counseling Center will not be held liable for personal information that you as the client choose to send via email or text should your confidentiality be compromised.  You also understand that emails should only be used for scheduling or exchanging information pertaining to appointments. The Counseling Center will not respond to personal content sent via email unless it is requested. Should you need to speak with your counselor in-between sessions regarding topics other than scheduling, you agree to do so by phone.

Records: Client records are held according to Texas State Board of Examiners Professional Counselors - code of Ethics Subchapter C. (681.41) or according to Texas State Board of Marriage and Family Therapists.  Your therapist is required by law to maintain records of each time you meet or talk on the phone. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. If records are requested for any purpose, our policy is to provide an appropriate summary, as records can be misinterpreted.

Release of Information:  If information needs to be released it will only be done according to state law and with a written consent from the client indicating an informed consent of such release. In the case of marital therapy, the client is the couple, not individuals; therefore, all records can only be released when both parties consent in writing or if mandated by the court.   Additional information is provided in our Privacy Policies document.

Incapacitation/Death: I acknowledge that, in the event the undersigned therapist become incapacitated or dies, it will become necessary for another therapist in the Counseling Center to take possession of my file and records. By signing this information and consent form, I give my consent to allowing the Director of the Counseling Center to assign my records to another counselor and provide me with copies upon request or to deliver them to a therapist of my choice.

Fees and Payment: Counseling Center are provided free of charge for students, staff, and faculty of Southwestern Assemblies of God University.  In such case that a client needs a referral to an outside provider, the client will be responsible for fees and payment to that provider. 

Video/Audio Taping of Sessions:  In order to provide the highest level of care to clients, your counselor may request to audio or video record your sessions for review and consultation. This information will be kept confidential and you will be informed of any intent to record a session and may decline at your discretion.  

Therapist Availability/Emergency Information: It is our desire to serve you in the best possible manner.  For needs outside of sessions, such as scheduling or other concerns, please contact the office at 972.825.4721.  We attempt to return non-emergency calls within 24 hours.   If you experience an emergency situation for which you feel immediate attention is necessary, we will attempt to accommodate a short notice appointment.  However, if that is not possible or the circumstances require immediate intervention, you should notify your Resident Assistant and Dorm Pastor.  If you live off campus, you may contact Campus Security at 972.923-5400 and request to speak with the Counselor-on-Call. Calls to Security are recorded and logged, but you do not need to identify yourself when requesting to speak to the Counselor-on-Call.  If a situation is possibly life threatening, please contact emergency services (911). Please do not use e-mail, text, and faxes for emergencies.

Your First Appointment: During your first visit, you will spend time with a counselor discussing your immediate concerns.  This will help both you and your counselor decide how Counseling Center can best assist you.  These services may consist of individual counseling, marital counseling, group counseling, or psycho-educational classes. In some instances, you may be referred to an off-campus service for longer-term, intensive therapy or some other mental health expertise not offered through the Counseling Center.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to the many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc....), neither you (client's) nor your attorney's, nor anyone else acting on your behalf will call on your counselor to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon. If you do become involved in litigation requiring your counselor's participation, you will be expected to pay for the professional time even if your therapist is compelled to testify by another party.

Social Media Policy: To protect the boundaries of our relationship no connection will be created to any counselor's personal social media account such as Facebook, Twitter, LinkedIn, etc. However, we do have professional business pages available to remain connected with the counseling center.

Minors:  Minors must have parental consent for counseling with the exception that the client: is 16 years of age or older and resides apart from the parents/guardians and manages his/her own financial affairs; is thinking about suicide; has concerns about alcohol or drug addiction/dependency; or is being sexually, physically, or emotionally abused. Consenting parents have the right to examine the treatment records of children under the age of 18; however, in order that minors may have the trust of a protected environment, it is your counselor's practice to ask parents to forego that right (they are willing to discuss progress with the parent/guardian) with the exception of extreme circumstances (see confidentiality above).    At the termination of treatment and upon request, your Counselor will provide the parent(s)/guardian(s) with a summary of treatment. It is important to note that in the state of Texas children under 17 may not have consensual sex (by law it is considered indecency with a child and therefore "child abuse'') and the state requires a therapist to breach confidentiality and report such activity to Child Protective Services. If your counselor is required to make such a report to CPS about your child, you will be informed as well.

Professional Consultation.  Professional consultation is an important component of a healthy psychotherapy practice.  As such, your therapist may participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, your therapist will not reveal any personally identifying information regarding you or your situation.  

Termination/Referrals: The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. If at any time you determine you want another professional's opinion or wish to consult with another therapist, you therapist will assist you in finding someone qualified, and with your written consent, will provide him or her with the essential information needed. You have the right to terminate therapy at any time.

HIPAA/HITECH:  The Counseling Center is required by law to maintain the privacy of and provide individuals with a copy of our "Notice to Privacy Practices" of our ethical and legal duties in regards to your protected health information in all forms (i.e. all paper and/or electronic data). A copy of this notice is on our website, attached with this informed consent and available in paper form. A copy will be provided to you at no cost upon your request.  . If you have any objections to the Notice, please ask to speak with our HIPAA/HITECH Certified Office Administrator in person or by phone at our main phone number.  FERPA statement?

I have read, understood, agree, and consent to the above conditions of service stated. I have also received the notice of privacy practices on this date and have had the opportunity to ask questions about and understand these policies.

Client Signature                                                                                                             Date

Client Signature (Spouse in case of marriage counseling)                                                Date

( Type Full Name )
Notice of Privacy Practices

 NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY AND KEEP A COPY FOR YOUR RECORDS.

I. OUR RESPONSIBILITIES: We are required by applicable federal and state law to maintain the privacy of your health information and inform you of our privacy practices, legal obligations, and your rights concerning your health information. We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted will be posted on our website and can be made available at your next appointment.

II. WHAT IS "PROTECTED HEALTH INFORMATION" (PHI)? Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the client and relates to the client's past, present or future physical or mental health or condition and related health care services.

USES AND DISCLOSURES OF INFORMATION: Under federal law, we are permitted to use and disclose protected health information, excluding psychotherapy notes, without authorization for treatment, payment and health care operations.

III. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE? Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.

IV. HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

-  Medical information may be used to justify needed patient care services, (i.e., treatment protocols).

-  We will use medical information to establish a treatment plan.

-  We may disclose protected health information to another provider for treatment (i.e. referring physicians, specialists and providers, therapists, etc.)

-  We may use medical information for the supervision of LPC and LMSW Interns or in consultation with other professionals.

-  We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment). We will submit only the minimum amount of information necessary for this purpose.

-  We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.

-  We may contact you to remind you of your appointment by calling, emailing, or texting you.

-  We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.

V. WHAT ARE PSYCHOTHERAPY NOTES? Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Psychotherapy notes will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.

VI. WHAT IS PSYCHOSOCIAL INFORMATION? Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.

VII. SHARING INFORMATION WITH BUSINESS ASSOCIATES

There are some services provided through contracts with business associates. Examples include billing services and receptionist services. When these services are contracted, we may disclose information as relevant to the business associate so that they can perform the job we have contracted them to do.

VIII. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?

The law requires that some information may be disclosed without your authorization in the following circumstances:

- In case of an emergency

- If you appear to pose an imminent threat to yourself or others, in order to reduce the likelihood of harm

- When there are communication or language barriers

- When ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even without a court order

- When required by law

- When there are risks to public health

- To conduct health oversight activities

- To report suspected child abuse or neglect or abuse/neglect to other disabled persons

- To specified government regulatory agencies including proof of compliance with regulations that safeguard your information

- To coroners, funeral directors, and for organ donation

IX. YOUR PRIVACY RIGHTS

The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

1. You have the right to inspect and copy your health information.

This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. All requests must be in writing. We reserve the right to deny access to your records. We will charge a fee for the costs of copying and sending you any records requested. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

2. You have the right to request a restriction of your health information.

This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction (such as non-disclosure to health insurance) by contacting your counselor.

3. You have the right to request to receive confidential communications by alternative means or at alternative locations.

We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.

4. You have the right to request amendments to your health information.

This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing and explain why the information should be amended.

5. You have the right to receive an accounting of disclosures of your health information.

You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.

6. You have the right to receive a paper copy of this Notice of Privacy Practices.

X. WHAT IF I HAVE A QUESTION / COMPLAINT?

If you have questions regarding your privacy rights, please speak to your counselor directly. If you believe your privacy rights have been violated, you may file a complaint by contacting your counselor, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:

Office of Civil Rights, U.S. Department of Health and Human Services, Atlanta Federal Center, Suite 3B70, 61 Forsyth St., S.W., Atlanta, GA 30303-8909, (404) 562-7886 (phone), (404) 562-7881 (fax), (404) 331-2867 (TDD), www.hhs.gov/ocr/hipaa

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

In our Notice of Privacy Practices, we provide you information about how 2:10 Living Counseling & Education can use or disclose your mental health and medical information. As described in our Notice of Privacy Practices, we request your consent for any use or disclosure of mental health and medical information necessary to carry out treatment, payment or health care operations. Be advised that my Notice of Privacy Practices is subject to change.  The most recent version will always be at my website at www.210Living.org.   If you have any questions about my Notice of Privacy Practices or if you need to request a copy, please contact me at the address and /or phone number below.

You have the right to revoke this Consent in writing at any time, except where we have already used or disclosed your health information in reliance upon this Consent.

I acknowledge receipt of the Notice of Privacy Practices of 2:10 Living Counseling and Education Services and consent to the use and disclosure of my personal health information for treatment, payment or health care operations, as described in the Notice of Privacy Practices.     

Signature:  ______________________________________       Date: ___________________

                            (patient)  

Signature:  ______________________________________       Date: ___________________

                            (parent/conservator/guardian)  

 This Notice is effective as of August 1, 2014.
( Type Full Name )