The decision to enter into counseling is personal and can lead to solutions to specific problems and reductions in feelings of distress. Counseling begins with an understanding of what to expect as a client as well as what your rights are. Information is given here that should be reviewed with your therapist prior to beginning therapy. Additionally, as required by law, a copy of the mental health bill of rights is posted in the waiting area.

Confidentiality: Under New Hampshire law, communications between a client and a licensed psychotherapist are privileged and may not be disclosed without the written authorization of client except under specific, limited circumstances. Among the exceptions to confidentiality are New Hampshire reporting laws which require licensed psychotherapists to report to the appropriate authorities in the case of physical or sexual abuse, neglect or endangerment of a minor or incapacitated adult. Psychotherapists are also required to warn the police or a specifically named victim of an intended act of physical violence. Confidentiality will also be suspended in the event of suicidality. If any of these circumstances occur, action will not be taken without discussion as to whom will be notified, why and what to expect.

Recordkeeping: Records are kept and securely maintained for seven years for each client, couple or family. Such records include a billing file and a clinical file which will contain assessment notes, diagnosis, the date of each session, a brief summary of clinical content, treatment recommendations and a discharge summary. Clinical records are securely stored by the therapist and contain a copy of this agreement, any releases signed, any additional diagnostic reports, summaries of other written information received by the client as well as documentation of communication requested with additional parties. Records may be requested and/or reviewed upon request. Ideally, discussion should take place with your therapist as to why this request is being made to further protect privacy.

Treatment Planning: Over the course of your or your child’s treatment, you will be an informed participant as well as a collaborator in this process. You will be aware of your/their diagnosis, the direction of your/their therapy, recommendation, rationale and expected outcomes. Your therapist will also discuss the insurance limitations to the number of sessions.

Treatment of Couples and Families: Treatment notes from couple or family sessions contain information about each person. All parties should be aware that records may be requested and released to any party, unless an agreement is made in advance that records will only be released by joint consent. In the event of a legal disagreement, records will not be released without a court order. This matter should be discussed in a thorough manner with your therapist.

Treatment of Minors: The treatment of minors must be authorized by a parent or guardian, except in some limited cases where minors have the right to confidential treatment. In the case of divorce/separation, both parents must give permission unless there is a compelling reason why this contact should not take place. Parents will be appropriately involved in their child’s treatment and despite minors not being granted full confidentiality by law, should respect their child’s privacy. This matter shall be thoroughly discussed with both the parents and in an age appropriate manner to the minor. Minors should be aware that guarantees cannot be made about release of records and other information to their parents. However, every effort will be made to advocate for a minor’s privacy.

Availability: Each therapist has a direct phone extension and schedules their own appointments. Phone messages are checked frequently, are heard only by your therapist, and will be returned as soon as schedule allows. Each therapist will discuss emergency contact information with you directly. In a significant clinical emergency please go to the nearest hospital emergency room for help.

Cost of Services: Fees for services are expected at the time they are rendered and are billed at $130 per 60 minute session. If you have insurance coverage, we will submit claims for you. However, you will be responsible for copayments and/or plan deductibles. This payment is expected at each visit. A $50 charge will be made for missed sessions or same day cancellations (within 24 hours). Insurance does not cover this charge. If additional professional services are required such as writing letters, reports, meetings or telephone calls on your behalf, or court appearances, fees will be charged at the rate of $130 per hour. Insurance does not cover this charge.

Statements of Understanding: I give consent for evaluation and treatment to be provided for myself/my child at the Family Guidance Center of Milford.

I am aware that the practice of psychotherapy is not an exact science and that results cannot be guaranteed. No promises have been made to me about the results of treatment.

The risks, benefits, side effects, and alternatives of treatment as well as the consequences of non-compliance with treatment have been discussed with me and I have had the opportunity to ask questions.

I understand that I will need to provide accurate information about myself to my therapist so that I will receive effective treatment. I also agree to play an active role in my treatment process.

I understand that I may terminate treatment at any time.

If insurance is billed for services, I authorize the release of information necessary to obtain authorization and process my claim. Information required by insurance companies includes a diagnosis, symptoms and when necessary a treatment plan to request additional sessions.

I understand that all insurance information is pending final authorization and not guaranteed. I am financially responsible for the full amount billed for services, including copayments, deductibles, and charges for missed appointments.

I understand I may discuss concerns about treatment, privacy, billing, or any other practices with my therapist. If I feel these concerns are not addressed to my satisfaction, I may contact the Agency Director, Anna Girard, at 603-554-7435.

My signature below shows that I understand and agree with all of the above statements. I have had the opportunity to ask questions about the treatment process. If the client is a minor or has a legal guardian appointed by the court, the client’s parent or legal guardian must sign this consent.