Therapy Philosophy Form

Treatment Philosophy Form

Read All Information and Sign Form Below.

Kimberly L. Hillery & Associates, PLLC, believes in providing goal-directed treatment. This means that a treatment goal or several goals are established after a thorough assessment. All treatment is planned with the goal in mind, and progress is made toward accomplishing that goal time-efficiently. Counseling is not an exact science with guaranteed, predictable results, and that guarantee cannot or has not been made concerning my needs. I understand that my therapist will make their best effort to assist me as appropriate.  However, I hereby release my therapist from any liabilities from counseling techniques and/or ordinary professional negligence and/or for actions concerning counseling. As such, I hereby consent to treatment, understanding that I can terminate this contract at my discretion. If you have any questions about the nature of the treatment or anything else about your care, please do not hesitate to ask.

TREATMENT PLANNING: A treatment plan describing the length, type, and goals of treatment will be developed and signed by you and the counselor no later than 30 days after admission. (No treatment plan will be devised for 1-5 session EAP Model unless otherwise stated).

FINANCIAL TERMS: Upon verification of health plan/insurance coverage and policy limits, your insurance carrier will bill you, and the carrier will pay me directly. You will be responsible for any applicable deductibles and co-payments. Co-payments must be paid at the time services are rendered. If you are not eligible at the time services are rendered, you are responsible for full payments. The established fee for services is due at the time of service unless an agreed-upon plan of payment has been established between this agency and the client.

CONFIDENTIALITY: The Confidentiality of Alcohol and Drug Abuse Patient Records maintained by this program is in accord with Section 42, Code of Federal Regulations, Part 2, as amended in 1975 42 CFR, Part 2, prohibits a program from disclosing to a person outside the program that a client attends the program, or from disclosing any information identifying a client as an alcohol or drug abuser, unless:

1) The client authorizes the release of information with his/her signature. 2) The client presents a physical danger to self. 3) The client presents a danger to others, 4) Child/elder abuse/neglect is suspected, 5) The disclosure is allowed by court order, or 6) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

Violation of the Federal Law and Regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal Regulations. Federal laws and regulations do not protect any information about a crime committed by a client, either at the program or against any person who works for the program, or about any threat to commit such a crime. Federal Law and regulations do not protect any information about suspected child abuse or neglect from being reported under State Law to appropriate State or local authorities. Clients will maintain strict confidentiality concerning the identity, attendance, and treatment of others participating in the program. All clients will receive information on all applicable confidentiality regulations.

CANCELLED OR MISSED APPOINTMENTS: A scheduled appointment means that time is reserved only for you. If you cannot attend your scheduled appointment, you are encouraged to contact the office and cancel twenty-four (24) hours before your appointment.           

EMERGENCY PROCEDURES: If you need to contact me, leave a message according to the instructions on the phone services, and your call will be returned within 24 hours. If an emergency arises, please follow the procedures and/or state that your call is an emergency. Please do this for genuine emergencies only.          

ZERO TOLERANCE POLICY:  1) No alcoholic beverages or drugs are allowed on the premises.  All violators will be asked to leave and may be subject to immediate discharge from the program. (This rule does not apply to medication prescribed for medical illness.)  2) Clients will refrain from disruptive and/or violent behavior, threats of violence, and inappropriate language. 3) Weapons of any kind are not allowed on the premises.      

TREATMENT AGREEMENT: I acknowledge that I am voluntarily authorizing counseling for myself at KIMBERLY L. HILLERY & ASSOCIATES, PLLC, and have been informed of the practices, policies, and procedures as listed below: