Humane Rescue Alliance

Individual and Group Debrief Support - Agreement

Jessica Kwerel, LPC, LCPC
www.petlossdc.com
jessica@petlossdc.com
(202) 642-2682

I am looking forward to working with you and supporting you. Please read this information carefully. The purpose of this Agreement is to set forth the details about working together so that we both are clear as to what each of our respective roles are and how our communication will take place so that our time will be positive, productive, and comfortable. Please read the entire document carefully and be sure to ask any questions that you may have regarding its contents.

This Agreement is being made between Jessica Kwerel (“I” and “me”) and the individual named at the bottom of this document (“Client” or “you”). We both agree to the following:

individual and group debriefing session description

I provide individual and group debrief services in two ways: 1. Online using a secure live video online platform (Zoom for Healthcare professionals). This platform is HIPAA-compliant. 2. In-person at Humane Rescue Alliance. Individual debrief sessions are 30 minutes and group sessions are one hour.

scheduling and timing:

You can schedule a session with me by emailing me directly or through a sign up link. My email is jessica@petlossdc.com.

If you need to reschedule or cancel your debrief session, you need to do so at least 24 hours in advance of your scheduled time by sending an e-mail to me.

debrief v. therapy: the services being provided are debrief services, not therapy.

Even though I am a licensed therapist, this modality that you are choosing is not therapy. Therapy and debriefing are similar in many ways but debriefing does not involve the diagnosis or treatment of mental disorders as defined by the American Psychiatric Association. By signing, you agree that you understand that debriefing is not a substitute for counseling, psychotherapy, social work services, mental health care or substance abuse treatment and you will not use it in place of any form of diagnosis, treatment or therapy. By signing this Agreement, you are agreeing that you understand the difference in these two functions and you will get appropriate professional help for mental health issues if necessary. Please free to ask questions at any time.

client responsibilities

You are solely responsible for creating and implementing your own physical, mental and emotional well-being, decisions, choices, actions and results arising out of or resulting from your sessions with me. As such, you agree that I am not, and will not be, liable or responsible for any actions or inaction, or for any direct or indirect result of any services provided by me. You acknowledge that debriefing is not therapy and does not substitute for therapy if needed, and does not prevent, cure, or treat any mental disorder or medical disease. You further acknowledge that you may terminate or discontinue my services at any time.

confidentiality   

As a Licensed Professional Counselor, there are some situations in which I am legally obligated to breach confidentiality in order to protect you or others from harm. If I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate county/state agency. If you report or appear, in my professional opinion, to be at imminent risk to harm yourself, or you make threats of imminent violence against someone else or property, I am required by law to take protective actions.  

I am ethically bound to protect the confidentiality of our communications and will do so. I will only release information about our work to others with your written permission or in response to a court order. If such a situation occurs, I will make every effort to discuss it with you before taking any action.   

Please note that it is impossible to guarantee the confidentiality of information that is transmitted electronically. This is particularly true of e-mail and information stored on computers that are connected to the internet; especially when there is not some form of security protection in place.   Please take proper precautions to protect any sensitive or private information that you wish to share with me. 

credentials

I am 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). I am also a Board Approved Clinical Supervisor in Virginia.

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.