Parkwood Counseling:Michael Rivera LPC: Information, Authorization, and Consent for Treatment

Please arrive 10 minutes prior to your session start time.

This relationship works in part because of the roles held by each person.You have certain roles that are important for you to know about because this is your opportunity for healing and development. I believe people can recover, and so can you.


My Responsibilities to You as Your Counselor:

I. Confidentiality

Sessions are confidential. I may want to speak with another about you with your consent, yet this is very rare. I will always act so as to protect your privacy even if you do consent to share. You may have me share information with whomever you choose, and you can change your mind at any time. You may request anyone you wish to attend a therapy session with you.

If you elect to communicate with me by email or electronic media at some point in our work together, I am willing to respond briefly, but please be aware that email and other electronic media are not completely confidential.

The following are legal exceptions to your right to confidentiality: If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.

If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or an ambulance. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call 911.

If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. 


II. Record-keeping

I keep brief records of each session noting the dates and times we meet, the topics we cover, reports of the client’s perspective, interventions, impressions and next steps.

III. Other Rights

You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better.

You can feel free to ask me to try something that you think will be helpful.

You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you.

You are free to leave therapy at any time, although I recommend finding a way to give me advance notice so that I can help you end treatment well.

Because I have a limited practice, I do not have 24 hour emergency or “on call” coverage. If you believe you will need a therapist with 24 hour coverage I will be happy to make a referral.

If you experience an emergency, you should call 911 or go to the nearest hospital emergency room rather than waiting for me to call you back.


IV. Fees

Individual therapy is $130 per 50 minute session. Couples therapy is $260 per 100 minute session.

You will be asked to pay for each session at the time of the session.

Payment can be by check, cash, or credit card (there is a $4 surcharge for the credit card, as this is not my usual form of payment).

V. Ending Therapy Well

I want to make your counseling experience as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. I will also do my best to offer you a referral to other sources of care, but cannot guarantee that they will accept you for therapy or how they will approach your treatment.


My Training and Approach:

My approach is usually psycho-dynamic, interpersonal and cognitive behavioral, with the use of Christian humanism and existentialism. I am seminary trained. I have a BA in Music with a minor in Biblical Studies. I have an MS in Counseling with a minor in Theological Studies. I have been in practice since 2005. I may suggest that you get involved in additional forms of support, such as a support group as part of your work with me. If another person is working with you, I may ask you if I can communicate freely with that person about your care.


Your Responsibilities as a Therapy Client:

You are responsible for coming to your session on time and at the time we have scheduled. Please arrive ten minutes early. Sessions are 50 minutes or more. If you are late we will still endeavor to end on time and not run over.

If you miss a session without canceling, or cancel with less than forty-eight(48) hours notice within business hours (Monday-Friday), you will be charged a $130 missed session fee. Payment is due at the start of the session. There is also a $4 surcharge for using a credit card as this is not my usual form or payment (Cash or Check please).

If you’re unhappy with what’s happening in counseling, I hope you’ll talk about it with me so that I can respond to your concerns.


Client Consent to Counseling:

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality. I understand the fee per session and my role as a client, and my counselor’s responsibilities to me. I know I can end therapy at any time I wish.

Starting therapy with Michael Rivera signals agreement with these policies