INFORMED CONSENT Thank you for choosing AZ Center for Change as your provider to help you through the issues that brought you here. This document will provide you with some important information about your experiences in counseling. Please read through it, and then sign it at the end. You may obtain a copy of this document from our website or you can ask your therapist to provide you with a copy. CREDENTIALS: AZ Center for Change is has Licensed and non licensed counselors. The Director, Diane Genco MA, LPC, has a total of over 20 years experience counseling individuals, youth and families. Feel free to inquire about any qualifications your counselor may have. Our agency is licensed by the AZ Office of Behavioral Health Licensing. GOALS OF COUNSELING: The goals of our work together will be decided in collaboration. Ultimately, you will decide when you think your goals have been met. At the beginning of the counseling process, your counselor will assist you in identifying problem areas and goals you wish to achieve. These will be evaluated periodically and modified as needed. If you are court ordered, treatment goals are identified in conjunction with the reason you were ordered for treatment. Treatment is individualized to meet your specific needs. SERVICES PROVIDED: The AZ Center for Change provides individual, family, couples and group counseling. Our specialization is in several areas including family problems, sexual abuse (both victim and offender), and a variety of general life issues. The types of counseling approaches that may be used in sessions are: cognitive/behavioral, solution focused, strategic, emotive or experiential, psychoeducation, guided imagery, and bibliotherapy. Types of counseling that we do not do include, psychopharmacology (medication prescribing), holding therapy, rebirthing therapy, or any other form of treatment that has been deemed damaging or inappropriate by the American Counseling Association or ethical guidelines. CLIENT EXPECTATIONS: Because counseling requires active participation on both the client and the counselor’s part, there will be some things that will be expected of you as a client. They are:

 Show for scheduled appointments (on time) (2 no shows in a 30 day time frame may result in      

involuntary termination from treatment). Excessive no shows and/or cancelations may result in involuntary termination from treatment and no show fees. Participate in your own treatment planning Actively participate in your counseling by following through with agreements made in session or assigned tasks or homework assignments Pay for your counseling prior to or immediately following your session (includes any co-pays). Take risks in sessions when discussing sensitive information Be as honest as you can with your counselor Express any concerns you may have about the process

Appointment availability varies with the client load at the time. High demand appointments (off hours, late afternoons, evenings) are likely to be sporadic in their availability. We reserve the right to limit our commitments

of high demand appointment times to any particular client in order to meet the needs of all our clients and balance our workloads. LENGTH OF COUNSELING: We find that most people are comfortable with meeting once a week or once every other week. If you feel that you might want to meet more frequently, please discuss this with your counselor so that viable options can be discussed. NOTE: If you are being referred for mandatory treatment, i.e. probation, parole, CPS or other, the length of counseling will be determined based on those requirements and your counselor’s recommendation together. Individual session time will be approximately 50 minutes, this is standard across the nation. Group sessions will run approximately 100 minutes. The number of times we meet will be based on several factors and we will decide together. If your insurance company is paying for your sessions, in most cases, the number of sessions may be limited. If your counselor feels you may need more than what is provided, your counselor will discuss that with you during the intake session and can discuss options available to you for continued sessions. Note RE: EMDR sessions: It is important you understand that if you are undergoing EMDR sessions with your therapist, these sessions tend to run 90 minutes long. Our agency charges by the hour, then quarter hour after that, not per session. Therefore, if you are paying for your services, you will be required to pay the amount according to time spent. COFIDENTIALITY AND MANDATORY REPORTING: As a client you are entitled to confidentiality. This means that nothing that is discussed during sessions can be communicated in any way to anyone else. However, by law, there are some limits to confidentiality. In rare circumstances we may be required to release confidential information. Those instances include:

 If you threaten grave bodily harm or death to yourself or to any other person, we are required by law to inform the intended victim and appropriate law enforcement agencies

 If a court of law issues a legitimate subpoena, we are required by law to provide the information specifically described in the subpoena

 If you reveal information which gives us a reason to suspect child abuse or neglect, we must report our knowledge or suspicions to the local child protection agency

 If our credentialing board requests information for any investigation they are doing related our services provided to you.

 We can also release any specified information with your written permission If you are court ordered or mandated in some way for treatment, we will be requesting you sign a consent form that allows us to communicate verbally and through written reports with your referring person (parole/probation officer/CPS, etc). RECORD KEEPING: We are required by our profession to keep adequate records and take all reasonable precautions to store them in such a way as to maintain confidentiality. Your counselor will be taking notes during sessions, this is to provide a record of our work together and refresh your counselor of any suggestions or treatment direction. We keep paper records stored in files in a locked filing cabinet which is in a locked office. You should also know that we, keep electronic records in our Web based client management system. This system is secure and only those with a valid password may access the system. Additionally, unless your counselor is an administrator within the agency, only your counselor and others assigned to your case will have access to your electronic record. We have researched AZCFC: Informed Consent: Revised 11.1.2011 Page 2 of 5

and taken every security precaution we can to prevent someone from accessing files on our computer. However, you should know that in case of a theft of our computer equipment, someone with extensive computer knowledge could bypass the security program and access files. If you are concerned about this, please let your counselor know and we will make every attempt to use only hand written records. You have a right to review and have copies of documents we create that are considered part of your clinical record. The agency has a policy regarding releasing records directly to clients. If you would like copies of your clinical record, you must request that in writing and submit it to the Clinical Director. No records are released to clients without reviewing them with the Clinical Director first. The only records you will have access to are the ones we create at our agency. We cannot release 3rd party records, which are records we receive from other professionals or agencies. You will be charged an hourly fee for the copying of the records and the meeting with the Clinical Director. The fee for this is our hourly rate.

FEES: You will be provided with our fee schedule and policy that clearly identifies our fees and payment expectations. We may participate in staffing meetings with your treatment team and this will also be charged at the hourly rate. If you have any questions about fees, please feel free to ask. In some cases your fees will be based on contractual rates made by this agency and the referring agency. Many of the contracts we have will cover your fees or you will be required to pay a copay for your services. Fees are collected at the time of service. If you feel you are having difficulty paying your fee, please discuss this with your counselor. Note to clients on public funding (i.e., AHCCCS, CPS, or other government funding): If you lose your eligibility for public funding for any reason, we will be happy to continue your services, however, you will become a private pay client and all information related to fees apply to you. RISKS AND BENEFITS OF COUNSELING: The benefits of counseling can provide you with better ability to handle or cope with marital, family, and other interpersonal relationships. Another possible benefit may be greater understanding of personal goals and values. This may in turn lead to greater maturity and happiness as an individual. Other benefits may relate to solving specific problems or concerns you brought to therapy. However, even the most properly performed therapy may not produce positive change, or it may produce change but not necessarily in the direction desired. Therapy requires that you make firm efforts to change your behavior and/or thinking. Changing either or both of these areas will also produce a change in feelings. Change is always uncomfortable. Usually we focus on the present, but sometimes we will focus on your memories of past events. Either way, our work together will be just that work. It may arouse intense feelings, such as anger, depression, fear, frustration, or anxiety. Clients often report that they feel worse before they feel better. Sometimes, in seeking to resolve issues between family members, marriage partners, or other persons, our work together may uncover previously unnoticed areas of discomfort. This may produce some relationship changes not originally intended. By training and by person predisposition, we will never take sides on these issues. You will be responsible for deciding if we need to focus on these new areas in our therapy or not. ABOUT OUR OFFICE: In order to keep our office clean and safe from hazards NO FOOD OR DRINK OF ANY KIND EXCEPT BOTTLED WATER is allowed in our suite. We kindly ask that you dispose of your food and drink prior to entering our office lobby.

For your safety our office building is equipped with surveillance cameras. These cameras are strategically placed around the perimeter of the building, in the parking garage, in front of the elevators, and in some of the hallways. AZCFC: Informed Consent: Revised 11.1.2011 Page 3 of 5

The cameras operate 24 hours a day, 7 days a week. There are no cameras at this time directly in our suite or any of our offices. INTERNET COMMUNICATION: Some counselors have found that using e-mail is a way of providing additional support for their clients. You are welcome to have e-mail communication with your counselor, however, you need to know that our ability to keep our communications confidential would be limited. Also, you should know that we communicate with your referring agent through e-mail. This is to provide better coordination of services. You will be asked to sign a special consent form that allows us to communicate through e-mail.

Counselor Supervision: This is to notify you that your counselor works under direct supervision and clinical supervision by a Licensed Behavioral Health Professional. Your counselor’s Clinical Supervisor’s name is Diane Genco MA, LPC. She can be reached at 602253-8488, 4205 N. 7th Avenue #311, Phoenix, AZ 85013. Ms. Genco is the Clinical Director/Owner of the AZ Center for Change. Your counselor will be meeting with the clinical supervisor and discussing your case and records on a regular basis. If you have any questions or concerns regarding this process, feel free to contact Ms. Genco at the above contact number.

Client Print __________________________________________ Parent/Guardian print

Client Sign Date ___________________________________________ Parent/Guardian Sign Date

Staff Witness Print

Staff Witness

Sign

Date

DIAGNOSTIC AND TREATMENT PLAN ISSUES: One of the standards of practice in our profession is properly assessing a client’s problem and forming an appropriate diagnosis using the current diagnostic manual. You should know that we may have to keep a record of your diagnosis in your file. Your insurance company may only provide payment for certain diagnoses. It is unethical for us to use a diagnosis specifically for the purpose of insurance reimbursement. We will make every effort to be as accurate and thorough as possible when diagnosing. Additionally, you will receive a comprehensive intake assessment prior to receiving services. We will review that assessment annually and update it as needed. Based on your assessment, your counselor will design with you a “treatment plan”. This is like a roadmap that will help both you and your counselor achieve your goals. If you are being referred here by the courts or CPS, some of your treatment goals may be predetermined. VIDEOTAPING/AUDIOTAPING: We have found that in many situations, video taping or audio taping sessions can be extremely helpful for both the client and the therapist. It can provide the client with before and after experiences that could not be obtained through reflection or discussion. It can provide the therapist with the ability to go back and review sessions to pick up on things that might have been missed during the session. Most people say they would feel uncomfortable being taped during session, however, we have found that within a few minutes, the client usually forgets the taping is occurring. We usually ask all clients to consider allowing us to tape our sessions. Feel free to discuss this further with your counselor if you have any questions. I agree to be video/audio taped (initial)

I do not agree be video/audio taped (initial)

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I have been provided with the intended outcome, nature and procedures involved in the proposed treatment, the risks including side effects (if any) as well as the risks of not proceeding and alternatives to the proposed treatment (particularly those offering less risk or other adverse effects); I understand that consent may be withheld or withdrawn at any time with no punitive action taken. I have read and understood all the above information concerning my counseling and all my questions have been answered. I consent to enter into counseling with AZ Center for Change.

Guardian Print

Guardian Sign

Client Print

Client

Staff Witness Print

Staff Witness

Date

Sign

Date

Sign

Date

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