The following information is to be completed by the person being served or the person’s authorized representative/parent.

 

The purpose of this document is to inform you, the client, about many aspects of online counseling services: the process, the counseling, the potential risks and benefits of services, safeguards against those risks, and alternatives to online services. Please read this entire document, sign, and return.  

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A. Process

1) Possible misunderstandings: The client should be aware that misunderstandings are possible with telephone and text-based modalities such as Store and Forward because nonverbal cues are relatively lacking. Even with video webcam software, misunderstandings may occur due to connection problems causing image delays or less than optimal image quality. Counselors are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online counseling before, please have patience with the process and clarify information if you think your counselor has not understood you well. Also, please be patient if your counselor asks for periodic clarification.

2) Turnaround time: Using asynchronous (not in "real time") communication such as messaging entails a “lag” of response. This is considered Store and Forward. The counselor will make every effort to respond to message requests within a 24-hour period. If the client is in a state of crisis or emergency, the counselor recommends the client contact a crisis line or an agency local to the client. Clients may also utilize 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).

3) Privacy of the counselor: Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. Michelle Quiroga, LPC, RYT has chosen to use VSee.com as the software provider for web conferencing, and chat communications between the counselor and clients. The client is responsible for securing his or her own computer hardware, internet access points, and password security.

The counselor has a right to his privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. Clients must seek the written permission of the counselor before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook, Instagram or YouTube.

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B. Potential benefits: The potential benefits of receiving mental health services online include both the circumstances in which the counselor considers online mental health services appropriate and the possible advantages of providing those services online. For example, the potential benefits of video sessions include the convenience for clients to potentially receive counseling from anywhere once an internet signal and necessary hardware is secured.

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C. Potential risks: There are various risks related to electronic provision of counseling services related to the technology used, the distance between counselor and client, and issues related to timeliness. For example, the potential risks of message based counseling may include (1) messages not being received and (2) confidentiality being breached, lack of password protection or leaving information on a public access computer in a library or internet café. Messages could fail to be received if they are sent to the wrong address (which might also breach of confidentiality) or if they just are not noticed by the counselor. Confidentiality could be breached in transit by hackers or Internet service providers or at either end by others with access to the client’s account or computer. People accessing the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen to people around them. Position yourself to avoid others’ ability to read your screen. Using cell phones can also be risky in that signals are scrambled but rarely encrypted.

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D. Safeguards: Your counselor has selected an account with VSee.com for messaging and video communications to allow for the highest possible security and confidentiality of the content of your sessions. In order to benefit from these safeguards, the client is required to download, register and utilize the chat and video software from VSee.com. Your personal information is encrypted and stored on a secure server in compliance with HIPAA regulations. For ease of use, Michelle Quiroga, LPC, RYT can assist you in downloading VSee.com. The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others, such as creating passwords to use the computer, keeping their email and chat IDs and passwords secret, and maintaining security of their wireless internet access points. The counselor and client will also choose a password in the first session to be exchanged at the beginning of all subsequent distance sessions in order to verify the identity of the client. Please discuss any additional concerns with your counselor early in your first session so as to develop strategies to limit risk.

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E. Alternatives: Online counseling is a non-acute service and may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving mental health services online would be receiving mental health services in person. Michelle Quiroga, LPC, RYT can and will assist clients who would like to explore face-to-face options in their area. Please feel free to request a referral at any time you think a different counseling relationship would be more practical or beneficial for you.

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F. Proxies: The counselor requires this consent form to be signed by the legal guardian of any client seeking services who is under the age of 18. The name and contact information of the legal guardian will be kept as part of the client’s record. Currently Michelle Quiroga, LPC, RYT is only seeing clients 18 years old and older.

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G. Confidentiality of the client: Maintaining client confidentiality is extremely important to the counselor and the counselor will take ordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with his or her express and written permission with the exceptions of the following cases: 1) If the counselor believes that someone is seriously considering and likely to attempt suicide; 2) if the counselor believes that someone intends to assault another person; 3) if the counselor believes someone is engaging or intends to engage in behavior which will expose another person to a potentially life-threatening communicable disease; 4) if a counselor suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult; 5) if a counselor believes that someone’s mental condition leaves the person gravely disabled.

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H. Records: The counselor will maintain records of online counseling and/ or consultation services. These records can include reference notes, copies of transcripts of chat and internet communication and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling Association, National Board of Certified Counselors and the Texas Counseling Association. The client will be asked in advance for permission before any audio or video recording would occur on the counselor’s end.

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I. Procedures: The counselor might not immediately receive an online communication or might experience a local backup affecting internet connectivity. If the client is in a state of crisis or emergency, the counselor recommends contacting a crisis line or an agency local to the client. Clients may utilize the following crisis hotlines: 1-800-SUICIDE or 1- 800-273-TALK (For the deaf or hard-of hearing: 1-800-799-4TTY).

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J. Payments: All payments will be processed through Paypal. Client understands payment of fees is expected at the time of service. Client agrees to pay for each service at the time it is rendered. Client understands they are responsible for all charges incurred, regardless of insurance status. Client will notify Michelle at least 48 hours in advance if they are unable to keep their appointment.

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K. Disconnection of Services: If there is ever a disruption of services on the internet then the client will need to call Michelle Quiroga, LPC, RYT to discuss how to proceed with the session. Michelle Quiroga, LPC, RYT can be reached at +1 (512) 717-1560 (US) or +52 (984) 269-7336 (Latin America).

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L. APPOINTMENTS:

COUNSELING: My practice is based on an hourly system and I function on a tight schedule. I begin the hour at the scheduled time, I hold a 60 minute counseling session. Even when you are late, I will still end on schedule. Individuals are expected to be available by phone during the session in case of an interruption in the teletherapy service.

APPOINTMENTS NOT CANCELLED 48 HOURS PRIOR TO THE MEETING TIME ARE CHARGED. If I am able to reschedule someone for that time, or I make the cancellation, you will not be charged.

CHARGES:

*Prices are is US Dollars.

• Webcam based Individual, Family or Couples Counseling: $100.00 – 60 minutes

• Phone based Individual Counseling: $70.00 – 50 minutes

• Reports, such as letters, are billed at $50 per page

• Mental Health Evaluations - $250.00  

• Emotional-Support-Animals Evaluations: $250

 PAYMENT IS DUE WHEN SERVICES ARE RENDERED. It is the responsibility of the client to maintain the account up-to-date to assure continuation of services.

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I am seeking services from Michelle Quiroga, LPC, RYT. The type and extent of services I receive will be determined following a consultation with Michelle and me. I will work with Michelle to develop a plan designed to assist me in attaining my goals. I understand that this is a collaborative effort between Michelle and me.

I understand that I have the freedom to choose to have counseling online by distance-counseling or teletherapy. I understand that there are risks to teletherapy, such as failure in technology or breaches of confidentiality. I understand teletherapy is a non-acute service.

By signing this consent I confirm I have read this document and understand its content, including confidentiality and its limits. 

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________________________                             ________________________

        (Full Name)                                                     Signature/Date

                              

If the parent/ guardian are undertaking the financial obligation for services please fill out the following:

I authorize Michelle Quiroga, LPC, RYT to consult with and undertake the counseling of ____________________ with the appropriate methods or techniques available to her.

 

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________________________                             ________________________

         (Full Name)                                                     Signature/Date

 

 

 

 

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· License No. and State:  Texas LPC #73295, New Jersey License #37PC00607700

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