Disclosure and Informed Consent Statement

Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client receiving counseling support, you have certain rights that are important for you to know about. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you, too.

Counseling Process

Counseling has both benefits and risks. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness), and/or the recall of unpleasant events in your life. Potential benefits include significant reduction of distress, and better problem-solving and coping skills. Counseling involves a significant commitment on your part, and you should feel comfortable with the therapeutic relationship. I can only counsel within the scope of my practice. If it is determined that you would be better served by a different provider, then I will make an appropriate referral.

Confidentiality

Counseling involves the disclosure of sensitive, personal information. Communication between a client and mental health counselor is protected by law. Information provided by and to a client during therapy sessions is legally confidential and cannot be disclosed without your consent. You should know, however, that it is the law and my policy only to accept clients who waive confidentiality under the following circumstances:

If there is suspicion of child or elder abuse or neglect, past or present.
If I determine that you are a danger to yourself or to others.
If you provide written consent to release information.
If a court of law issues a legitimate subpoena or if you are involved in criminal proceedings.

In addition, there may be times when I consult with an additional colleague or other Licensed Mental Health Professionals. Client confidentiality is protected during consultation.

If you elect to communicate with me by email at some point in our work together, I am able to respond briefly by return email, but please be aware that email and other electronic media are not completely confidential. I do not use an encryption program on email.

Emergency Services

My practice does not provide 24-hour emergency services. All phone messages and emails will be checked daily unless otherwise stated but are not for use in an emergency. In an emergency please call 911 or report to your local emergency room.

Insurance

My practice does not accept insurance.

Session Fees

My fees are $200 for individual sessions and $225 for couples and family sessions. Sessions are 60 minutes. I do require keeping a credit card on file so I can automatically submit payment for you.

Late Cancellation/No Show Fees

All sessions are by appointment only. Cancellations must be made at least 24-hours in advance of the scheduled session. You are responsible for the full session fee if you miss a session or cancel within 24-hours of the scheduled appointment.

Client’s responsibilities

As the client there are several responsibilities to make sure you are receiving the best services possible and benefits from these services. It is your responsibility to attend all scheduled sessions and call more than 24 hours in advance if you cannot attend your session. Repeated failures to attend sessions or to provide adequate rescheduling notice may lead to termination of services. Participating in counseling while under the influence of any mood-altering substances prevents any progress. If it becomes clear that you are under the influence, I will end the session and reschedule for a future date. A repeat occurrence will result in the termination of services (with referrals). Violent or threatening behavior may also result in termination of services and a police report.

Professional Records

I am required to keep appropriate records of the clinical services that I provide. Your records are maintained through my secure, HIPAA compliant electronic health record system. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. You also have the right to request that a copy of your file be made available to any other healthcare provider at your written request. By state law, records are kept for seven years after the end of treatment.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Grievances

If you are unhappy with what is happening in therapy, I hope you will will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of therapy and about my specific training and experience. Information to file a grievance, :

DC residents:

For complaints against a health care professional, mail to:
DC Board of Professional Counseling
899 North Capitol Street, NE
Second Floor
Washington, DC 20002

https://dchealth.dc.gov/service/file-complaint-against-health-professional-or-facility

Maryland residents:

https://health.maryland.gov/bopc/Pages/complaintold.aspx

Virginia residents:

https://www.dhp.virginia.gov/PractitionerResources/Enforcement/FAQ/

CO residents:

https://dpo.colorado.gov/FileComplaint

Credentials

Jessica Kwerel is a Licensed Professional Counselor in Washington, DC (PRC15039), Virginia (0701009407), Colorado (LPC0014760), a Licensed Professional Clinical Counselor in Maryland (LC13590) and certified by the National Board of Certified Counselors (NCC #238583).

esignature

Per the ESIGN Act, your esignature is legally binding. By signing your name electronically below, you are agreeing that your electronic signature (or esignature) is the legal equivalent of your manual signature.

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