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Chapel Hill Mental Health Information and Consent Form
This document is designed to provide you with information about your counselor and to ensure that you understand the professional relationship of the counselor and the client for individuals and any families entering mental health treatment with Family Circle of Care. 

Benefits, Purposes, and Risks of Therapy

Counseling can have both benefits and risk for individuals of all ages. The purpose of therapy is to help you explore and understand your personal patterns, clarify your goals, and develop effective coping strategies.  This process often involves discussing difficult aspects of life, which can bring up strong emotions such as sadness, guilt, anger, frustration, loneliness, and helplessness.  As a result, you may experience discomfort and, at times, temporary worsening of symptoms, including an increase in challenging behaviors among children receiving services. However, these challenges are often part of the therapeutic journey and typically improve as you or your child begin to utilize new skills and gain self-confidence. 

While there are no guarantees on how anyone will respond to therapy, many people find that it leads to better relationships, solutions to specific problems, significant reductions in distress, and improved self-esteem.  Counseling can be particularly beneficial in supporting individuals of all ages as they work towards reaching their fullest potential. 

Techniques and Approaches

Therapy may incorporate various aspects of your life including your thoughts, emotions, physical health, spirituality, culture, and medical needs. Counselors will work with you to develop a unique evidence-based treatment plan to address your specific needs. 

Areas of Competence 

Licensed Professional Counselors (LPCs) and Licensed Professional Counselor Associate collaborate with school counselors and staff to help clients succeed academically, socially, and emotionally.  Services will be provided by SanTanna Tave, MS, LPC (License #84972) or Karina Leon, MA, LPC Associate (License #90895 supervised by Melissa Ray, LPC-S License #72279).  These professionals examine issues that may be contributing to client difficulties and work to find the best solution for each client and situation

Voluntary Nature of Treatment

Some client's may need only a few sessions to achieve their goals, while others may require more time. Therapy at FCC is voluntary, with consent valid for one year.  You can withdraw your consent or end treatment anytime, but it’s recommended to have one final session for discharge planning and reinforcing coping skills. 

Confidentiality

Sessions are held confidential, and information discussed in sessions will only be shared with members of your disciplinary team at Family Circle of Care for the purposes of treatment, but the following limitations and exceptions do exist: 

1. Texas Family Code, Chapter 261, concerning abuse or neglect of minors; 
2. Texas Human Resources Code, Chapter 48, concerning abuse, neglect, or exploitation of elderly or disabled persons; 
3. Texas Health and Safety Code, Chapter 161, Subchapter K, §161.131 et seq., concerning abuse, neglect, and illegal, unprofessional, or unethical conduct in an in-patient mental health facility, a chemical dependency treatment facility, or a hospital providing comprehensive medical rehabilitation services; 
4. Texas Civil Practice and Remedies Code, §81.006, concerning sexual exploitation by a mental health services provider; 
5. A licensee shall comply with Occupations Code, Chapter 109, relating to the release and exchange of information concerning the treatment of a sex offender; 
6. I am directed by you in writing to disclose information to someone of your choosing; 
7. I am ordered by the court to disclose your information. 
8. You present as a danger to yourself or to others due to the presence of thoughts of self-harm or express to intent to harm another.

If I see you in public, I will protect your confidentiality. This means that I will not acknowledge that I know you, unless you approach me first. I will not discuss your case or details of your sessions in public.

Supervision of Minors

Clients at Chapel Hill High School and/or Chapel Hill Jr High with parental consent may walk to their scheduled counseling appointments on their own after getting approval from their school front office. For all other clients, children and adolescents must be escorted by an adult, parent or guardian to appointments. This person(s) is responsible for supervising the child while at the FCC to prevent behaviors disruptive to clinic operations or other clients. You may not leave your children unattended. While the child is in session, you must remain in the waiting area. This requirement does not apply to emancipated minors.

Emergencies

Family Circle of Care has an afterhours answering service that can take calls outside clinic hours for the mental health department at (903) 535-9041; however, this is not an emergency line. 

If a true emergency arises, please call 911 or the national crisis line 988.   You may also call the Andrews Center 24/7 crisis hotline (877-934-2131). 

Medical records and Use of Technology

Family Circle of Care uses, holds, and maintains an electronic medical record for the documentation of therapy and treatment services. Records can be requested through the clinic front desk.  

Complaints or grievances

Although clients are encouraged to discuss any therapy or malpractice concerns with their therapist or their supervisor, the following information is given if you wish to submit a formal complaint or grievance related to your therapist by calling the Texas Behavioral Health Executive Council at 1-800-821-3205. 

Additional client rights and privileges when receiving mental health services 
You have the right to:
1. Be informed about the name, qualifications, and areas of expertise of your psychotherapist including their education, experience, certifications, and licenses. 
2. Receive an explanation of the services offered, including methods of psychotherapy, techniques used, your commitments, fees, and billing policies prior to start of services.
3. Participate in identifying problems, setting goals, and evaluating progress toward meeting those goals.
4. Request a second opinion or seek a referral for a second opinion at any time.
5. Request copies of medical records and reports be sent to other counseling professionals.
6. End psychotherapy at any time, with the understanding that you will need to pay for any sessions you have already received. (This does not exempt you from possible consequences if therapy is court-mandated)
7. You have the right to ask questions about the counseling techniques and strategies and be informed of your progress.
8. Contact the appropriate professional organization if you have doubts or complaints about psychotherapist’s conduct.
9. Decline the use of any specific therapy techniques. 
10. Be treated with dignity and respect in a safe, private setting that acknowledges your cultural, social, spiritual, and personal beliefs and values
11. Request special accommodations if you have a disability
Agreement of Terms
By your signature below, you are indicating you have read, understand, and agree to this agreement. Any questions you may have concerning this agreement have been answered to your satisfaction.


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Family Circle of Care provides equal employment opportunities without regard to a person’s race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), national origin, disability status, genetics or any other characteristic protected by law.