Informed Consent for Michelle Coon, LISW

Professional Information:  I am a Licensed Clinical Social Worker in the State of Iowa and hold a Masters in Social Work from a regionally accredited institution.  I have experience in counseling working with children, teens, adults, and couples.  I draw from a variety of theories which I find to be biblically sound in order to consider your spiritual, psychological, social, and biological dimensions.

Counseling Relationship:  I believe counseling is a process whereby you are seeking to resolve interpersonal, emotional, and/or spiritual difficulties with the assistance of a caring professional.  As your counselor I will bring to the sessions my professional knowledge and experience, but the ultimate responsibility for growth and change rests with you.  Therapy can last from a few weeks to several months.  We will be in ongoing dialogue about your needs, progress, and recommended duration of therapy.  You are invited at any time to ask questions about my methods or the direction of your counseling.  If for any reason you are dissatisfied with my services, please let me know and I will try to resolve your concerns.  If we are unable to resolve your concerns, I will be available to assist you in finding qualified help elsewhere.  Occasionally, I may elect to discontinue therapy if I find factors interfering with my ability to help you that we are unable to resolve.  

Side Effects of Counseling:  You should know that counseling is not always easy.  You may find yourself discussing very personal information, and you may find these conversations difficult.   I may suggest changes for you that at first may make you feel awkward or uncomfortable.  As you learn more about yourself, you may encounter changes, some pleasant and some unpleasant in your relationships with family members, friends, co-workers, etc. 

Counseling can be a disruptive process as you seek to create the change in your life that you desire.  It is possible that you may at times become depressed, anxious, agitated, or feel some other emotional/physical discomfort as you proceed through this process.  You will always be free to move at your own pace and talk with me about any of these things that you may experience.  It is also important for you to understand that I cannot offer any promise about the results you will experience.  Your outcome will depend upon many things . . .  some of which are beyond my control.

If at any time I believe that your situation requires knowledge that I do not have, I may refer you for a consultation with someone with specific training or experience in that given area.  I will discuss any such referral with you before we act. 

Confidentiality:  Under normal circumstances everything you discuss with me will be held in strict confidence.  However, you should be aware that there are some exceptions in which I may be required to report information to proper authorities and/or an appropriate family member or friend without your permission.  If I believe there is a risk that you might harm yourself or someone else, I will be required to contact the authorities, a family member or friend, or the person being threatened to give them the opportunity to protect you and/or him/herself.  I am also mandated by the state of Iowa (State Law, Code Section 232 & 235) to report suspected incidents of child and/or dependent adult abuse. If you become involved in any legal issues in which your mental health is an issue (for example child custody disputes or an injury lawsuit resulting in emotional pain/suffering) the courts may insist upon and obtain your counseling information from me.

If you are utilizing third party payment, then your insurance company will need access to certain information, including (but not always limited to) your diagnosis and dates of your visits.  I will use my best judgment in both discussing these circumstances with you if they arise, and in disclosing only essential information when required. 

I may utilize the services of an administrative assistant to help with general bookkeeping.  This individual will have signed a confidentiality agreement and will have access to your name, billing, and insurance information.  They do not have access to any of the confidential counseling notes that I keep.

Finally, you should also know that I consult with other professionals as needed regarding clients with whom I am working.  This allows me to gain other perspectives and ideas as how to best help you reach your goals.  Such consultations are obtained in a way that your complete confidentiality is maintained.

Sessions, Fees, & Cancellations:  Counseling sessions normally last 50 minutes.  To best utilize your time, please come prepared with your ideas about how you can best use each session to your fullest benefit.  Also,  please share the responsibility with me in watching the clock so that we can bring each session to good closure in a timely manner.  The initial assessment session(s) fee is $175 and all sessions following are $160. For those not utilizing insurance, fees may be adjusted based on financial hardship.  Phone consultation will be charged in 15minute increments of $40 or a regular session fee of $160 for a 50minute session. This work would need to be private pay and is not eligible to be submitted to insurance providers.  It is expected you pay the fee at the time of each session.  If you have insurance coverage, your co-pay is due at the time of your visit.  If there is a problem collecting payment from your insurance company, you are personally responsible for payment of any remaining balance.  If you need to cancel an appointment you must notify me within 24-hours of that appointment.  Please call my office at 515-556-3939 and leave a message to notify me of your cancelation.   I have reserved your appointment expressly for you; failure to notify me within 24-hours will result in you being charged $90 for the missed appointment.  I understand that occasional emergencies do arise.  If this is the case, please contact me as soon as possible to inform me of the reason for the lack of 24-hour notice to discuss your situation.

Records Request: Please make records requests 2-4 weeks prior to your need for your records or as soon as possible.  There is a $200 records request fee.  Michelle Coon, LISW will provide a written compilation of your records or copy and release your records as you request.   

Appointments & Emergencies:  Appointments can be made following each session, or you may schedule appointments online at the link provided on my website:  www.daretomovecounseling.com.  You may also contact me via e-mail at daretomovecounseling@gmail.com, or call me at 515-556-3939 to schedule, however online scheduling is preferable, and most efficient.   If you call or e-mail, I will do my best to follow up within two working business days.  If you have not heard back from me after a reasonable amount of time, please try again as your message may have somehow been missed. 

If an urgent, but non-emergency need arises in between your sessions, you are welcome to notify me to request if you can obtain an appointment sooner than scheduled.  

If you have an emergency, promptly contact 911, your local emergency room, or crisis center.  Here are some other support options:

• You can receive immediate support thru a national crisis text line by texting "HOME" to 741741.
• You can call the NAMI Help Line at 1-800-950-6264 or you can access a variety of crisis care services from this website: namigdm.org/en/get_help/crisis_information/.
• You can call 211 which is a joint effort between the Red Cross and the United Way that provides information and direction to resources 24 hours a day 7days a week.

Electronic Communications:  You are welcome to communicate with me via e-mail or text regarding scheduling and other administrative concerns.  It is important to be aware that any electronic communication can be vulnerable to unauthorized access and I cannot guarantee the confidentiality of any electronic communication.  Like phone messages, if your electronic communication is not responded to in a reasonable amount of time, please follow up with a phone call to ensure that your communication was received.

Teletherapy Sessions via Telehealth:

Definition of Telehealth: Telehealth involves the use of electronic communications to enable mental health providers to connect with individuals using live interactive video, audio, or data communications. Telehealth includes the practice of mental health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.  

I understand that I have these rights with respect to telehealth:  

1. I understand that I have the right to withhold or withdraw my consent to the use of telehealth during my care at any time without affecting my right to future care or treatment.  Also, my mental health provider may determine at any time that due to certain circumstances telehealth is no longer appropriate and we shall resume our sessions in person.
2. I understand that there are risks and consequences from telehealth.  These risks include, but are not limited to the possibility, despite reasonable efforts on the part of the counselor, that:
• The transmission of my personal information could be disrupted or distorted by technical failures.
• The transmission of my personal information could be interrupted by unauthorized persons.
• And/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.
3. I understand that I am responsible to communicate through a computer that I know is safe, i.e. wherein confidentiality can be ensured.  I understand it is important to use a secure internet connection rather than public or free Wi-Fi.  I understand my responsibility to determine who has access to my computer and electronic information from my location which would include family members, co-workers, supervisors, and friends.  Additionally whether confidentiality from your work or personal computer may be compromised due to such programs as a keylogger.  I understand that it is my responsibility to fully exit all online counseling sessions from my computer at the conclusion of each session.
4. I understand that it is my responsibility to ensure the privacy and confidentiality of my space without distractions while utilizing telehealth.  I agree to show my mental health counselor this space if requested at the beginning of each session to ensure confidentiality.  Every effort must be made on your part to protect your own confidentiality.  It is suggested to wear a headset to increase confidentiality as well as increase the sound quality of our sessions.  I understand that all telehealth sessions will be provided by Michelle Coon.  Michelle Coon utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via Doxy.me which is reported and believed to be HIPAA compliant.
5. By signing this document I agree that certain situations, including emergencies and crisis, are inappropriate for audio-/video-/computer-based psychotherapy services.  If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

Payment for Telehealth Services: Dare to Move Counseling will bill insurance for telehealth services when these services have been determined to be covered by an individual’s insurance plan. The standard copay and/or deductibles will apply, and your card on file will be charged (other forms of payment can also be accepted; credit card, check, or cash).  If your insurance does not cover telehealth, or when there is no insurance coverage, you will be responsible for the fee.  If you need to cancel or change your telehealth appointment, please notify Dare to Move Counseling 24 hours in advance by phone or email (see the Sessions, Fees, & Cancellations section above for more information).

Recording Policy:  No sessions may be recorded without written permission by Michelle Coon LISW and all members of that session.

Patient Consent to the Use of in person care as well as Telehealth:  

I have read and understand the information provided above regarding in office, phone, and telehealth counseling sessions.  I have/will have discussed it with my counselor and all my questions have been answered to my satisfaction.  I have read this document carefully and understand the risks and benefits related to the use of in person, phone, and telehealth services and have had my questions regarding the procedure explained.  

I hereby give my informed consent to participate in the use of in office, phone, and telehealth services for treatment under the terms described herein.  By my electronic signature below, I hereby state that I have read, understood, and agree to the terms of this document.