This Informed Consent is intended to inform you of policies, state and federal laws, and client rights. If there are any questions regarding the information presented, please feel free to ask.
Michelle Staley (she/her) is licensed by the state of Illinois as a Licensed Certified Professional Counselor. She obtained her Master of Arts degree in Clinical Psychology from Illinois State University. She has been practicing since 1995 in various community settings.
Robert Lusk (he/him) is licensed by the state of Illinois as a Licensed Clinical Psychologist. He obtained his Doctorate in Clinical Psychology from U.C.L.A. and has been practicing since 1988. Our approach to therapy is typically client-centered and cognitive-behavioral.
Therapy can be a safe place to discuss feelings, identify life goals, and work on personal growth. There can be risks to therapy as well; therapy can bring about painful feelings or memories which may lead to an increase in the symptoms that bring clients to therapy. This is usually temporary and can often be resolved by continuing to work with those feelings or memories.
Confidentiality: The information shared in counseling is confidential with the following exceptions:
Managed health care companies will need the following before agreeing to reimburse a client or therapist: Name, address, date of birth, insurance member number, diagnosis, and dates of service.
Metta Counseling uses Dokbot, a HIPAA compliant service through doxy.me, to send post-session satisfaction surveys to clients, and to obtain client results. A client may opt out of this process.
Provider specific situations:
1. Michelle Staley, MA, LCPC, has Ménière’s Disease. This can affect treatment: If a vertigo episode occurs before a session, Michelle will need Robert Lusk, Ph.D., to look at her calendar, access text messages in her phone and text the scheduled clients. First names (and sometimes last initials if the client list includes more than one of the first name) are used in both her calendar and phone. The client will not be identifiable to Robert Lusk. However, if there is a text thread, he could potentially see it. Michelle has set her phone to delete all text messages after 30 days.
2. In the event of Michelle Staley’s death, Bryan DeNure, MA, LCPC, will have access to client records and notes in order to inform clients of the death, help assess current needs, and find another therapist.
Emergency situations: If an emergency arises outside of business hours, there are several options:
Financial options: This practice charges $150.00 - $200.00 per 50 minute session.
Please give this office 24 hours notice if unable to attend a scheduled appointment. The regular session fee will be charged for no-shows or cancellations without 24 hours notice (should this become a habit).
Coordination of treatment: If referred by a physician, we can inform her/him of treatment.
Client Contact: Most client contact is by email, text, or phone call unless the client specifies otherwise.
Notice of Privacy Practice and Clients’ Rights:
I have received and read a copy of the notice of Privacy Practice and Clients’ Rights documents.
My signature indicates that I have read and understood the above information including confidentiality, provider specific situations, emergency situations, financial agreements, coordination of treatment, client contact, and that I have received and read a copy of the notice of Privacy Practices and Client’s Rights documents.
I understand that I am responsible for my payment for each appointment. I agree to be responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. Metta Counseling will honor contractual agreements made with managed health care companies which stipulate specific reimbursement restrictions.
I hereby consent to treatment by the specified provider. Although the chances for obtaining my goals for therapy will best be met by adhering to therapeutic suggestions, I understand that I have a right to discontinue or refuse treatment at any time. I understand that I am responsible, however, for any balance due prior to a decision to stop.
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