Chikeitha Owens LPC 1

Informed Consent

Client Information Sheet:

Name: ___________________________________ Birthday _____________
Nickname: ________________________________
Age: _____________________________________
Address: _________________________________
Email: ____________________________________
Skype ID: _________________________________
Phone: Home: ______________________________ Cell: _______________
Emergency Contact: _________________________ Phone: _____________
Any additional information you would like me to know:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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Informed Consent

Acknowledgement of Receipt of Privacy Notice

This privacy notice provides information about how Chikeitha Owens may use and
disclose protected health information about you. You have the right to review this notice
before signing this and receive a copy if requested. As provided in this notice, the terms
of this notice may change. You may obtain a revised copy by contacting Chikeitha
Owens .
By signing this form, you acknowledge the receipt of this privacy notice.
__________________________________________________
Client Name Print
__________________________________________________
Client Signature
General Information and Counseling Agreement

_____________
Date

ORGANIZATION: The policies and procedures comply with applicable state

regulations. Chikeitha Owens is a Licensed and Registered Professional Counselor in
the State of Texas. By engaging with Chikeitha Owens , you understand that the services
provided are licensed in the state of Texas unless otherwise noted in the beginning of
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Informed Consent

your session. You agree to the terms and conditions of the State of Texas and the services
provided within this state. You agree and understand that the service you are receiving is
licensed therapy within this state. If you reside outside of the above-specified state (s),
you understand that it is not licensed services, but rather a confidential consultation.
Chikeitha Owens holds responsibility only to the state(s) in which she resides and is
licensed in and cannot be held accountable for any rules or regulations of other states
outside of her licensure and residence. Some sessions may consist of psychotherapy,
counseling, psycho-education, art therapy, or other wellness activities. I understand I am
receiving services at my own risk and hereby release Chikeitha Owens from any legal
ramifications should I injure myself in any way including but not limited to physical,
emotional, mental, or psychological distress or injury.
CONFIDENTIALITY: Under the law, what you reveal to your therapist is legally
privileged communication. You must sign a written release before any information
about your treatment is disclosed. The following are exceptions to the general rule of
confidentiality:
1. State laws mandate that all psychotherapists report all incidents of actual or suspected
child abuse or neglect, elder abuse, and dependent adult abuse. The law also requires that
incidents of threatened harm to self or others be reported. In addition, State law
requires us to report incidents of loss of consciousness to local health officials. Chikeitha
Owens complies with all prevailing laws.
2. In you are a minor (Under 14), we are required to answer questions your parents or
guardians might have about your progress. We do not have to reveal the details of what is
said during your session unless we have a consent about someones safety. Provider
discretion applies to minors ages 14-18.
3. Your therapist may make a diagnosis that documents the medical necessity of your
treatment. Your therapist may also make periodic treatment plans; which document that
treatment is being provided according to medical necessity. This information may be
requested by other health professionals or insurance companies (note, Abundance of
Hope does NOT work with insurance companies for Virtual Sessions). This information
is confidential unless you give written permission to allow Chikeitha Owens to
release this information.

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Informed Consent

I/We understand that Chikeitha Owens does not make custody recommendations nor
legal or court recommendations nor determine an individuals fitness to be a parent. I/We
understand that Chikeitha Owens can only provide verification that I/We are attending
counseling and participating in the process. I/We understand the records are confidential
unless a signed release of information or a court order allows the release of the records.
I/We understand that there are additional state laws and ethical issues that govern the
release of information to you or to certain parties. I/We understand that any relevant laws
or issues will be explained along with the process for challenging these laws or issues.
COMMUNICATION: Chikeitha Owens s, email is
chiowens316@abundanceofhope.com and is answered and monitored during regular
business hours from Monday to Thursday from 9am to 6pm CT. Digital diaries/Email
sessions will be answered within two business day if submitted before 5pm, CT., and
within 72 hours if submitted after 5pm, CT. Digital diaries submitted after 5pm on
Thursdays or on Holidays will be answered on the next business day. If you have an
emergency and are unable to reach your therapist, please call 911 or your States
Crises Hotline or the National Suicide Hotline at 1-800-784-2433. You may also go
directly to the emergency room nearest to your location.
SESSION LENGTH AND CANCELLATION POLICY: Sessions are 30 minutes long
at the scheduled appointment time. You may have a full 55-minute session. You must
arrive on time in order to have a full session. After ten minutes of a no show, your
entire appointment will be used and must be rescheduled. When appointments are
scheduled, that time is reserved for you. If you need to change or cancel an appointment
you must give 24-hour notice or you will be charged the full cost of the session and lose
your session.
FEE POLICY: Your agreed upon fee payment will be made on the Abundance of Hope
Website at the following link
http://abundanceofhope.weebly.com/store/c1/Featured_Products.html. 30 minute sessionexpires after 30 days of purchase which includes the choice of Video, Phone call or Email
chat session.- $50.00
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Informed Consent

30 minute session- no expiration date, which includes the choice of Video, Phone call or
Email chat session.- $70.00
55 minute session- expires after 30 days of purchase, which includes the choice of Video,
Phone call or Email chat session.- $100.00
55 minute session- no expiration date, which includes the choice of Video, Phone call or
Email chat session.- $120.00
All fee policy questions and concerns can be sent to
chiowens316@abundanceofhope.com
SPECIFICS FOR ABUNDANCE OF HOPE COUNSELING CLIENTS: By registering
for online, video, email or phone sessions and signing this consent, you are providing
informed consent to the terms and conditions and privacy policy listed for Abundance of
Hope Counseling. You ("Client") acknowledge that you understand the nature of online
counseling services as well as the duties, qualifications, and limitations of Chikeitha
Owens and that you have been provided with this information prior to providing you
with any professional services.
If you have any history of major psychiatric episodes, suicidal attempts or thoughts,
hospitalizations, hallucinations or drug/alcohol dependence or have been diagnosed as
any of the following disorders that include but are not limited to Personality Disorder,
Major Depressive Disorder, Bipolar Disorder Type 1, Mentally Ill/Chemically Addicted
(MICA), and/or Schizophrenia - you must disclose this information. In the event you
become symptomatic or your physical and/or mental well-being are deemed at risk, you
will be referred out to in-person treatment for primary support and Chikeitha Owens will
continue to work with you as adjunct supportive care.
Chikeitha Owens reserve the right to terminate services to any client found ineligible
for services, and may refuse all current or future use at any time.

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Informed Consent

IF YOU HAVE CONSIDERED OR ARE CONSIDERING SUICIDE, OR BELIEVE

YOURSELF TO BE A POTENTIAL THREAT TO THE SAFETY OF OTHERS, YOU
MUST IMMEDIATELY CALL 911 AND NOTIFY THE POLICE.
ADDENDUM FOR WORKING WITH COUPLES/FAMILIES: When seeing Chikeitha
Owens , if the unit of treatment is determined to be the couple or the family, a no secrets
policy will be implemented. Everything will be confidential between yourself, Chikeitha
Owens , AND your partner and/or family members. Chikeitha Owens will not be held
to the limits of confidentiality within the couple/family unit parameter and will not serve
or be expected to serve as a secret keeper. The options are as follows:
1. The couple/family may be seen under one session if all presenting parties are present. In
order for this to be a viable option, it must be determined and agreed upon with
Chikeitha Owens . Email journals will not be accepted. OR
2. Each member of the couple/family may have their own individual sessions. The
individuals may be seen or submit an Email/journal individually under their own session
and name. (Recommended).

YOU AGREE THAT BY USING THIS SERVICE YOU ARE AT LEAST 18 YEARS OF
AGE AND ARE LEGALLY ABLE TO ENTER INTO A BINDING CONTRACT.
ADDITIONALLY YOU AGREE THAT ALL INFORMATION SUBMITTED BY YOU
IS TRUE AND ACCURATE. A PHOTO ID WILL BE REQUESTED OF YOU BEFORE
YOUR TREATMENT BEGINS. YOU MAY EITHER EMAIL THIS TO
Chiowens316@abundanceofhope.com OR SHOW YOUR THERAPIST AT THE START
OF YOUR FIRST SESSION.
SIGNATURES:
I/We read and understood the above paragraphs and do hereby agree to abide by these
terms and conditions. I/We also have read and understood the Informed Consent do
hereby agree to abide by these terms and conditions. My signature on this consent is free
from pressure or influence from any person or entity.
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__________________________________________________
Client Name Print
__________________________________________________
Client Signature

_______________
Date

__________________________________________________
Chikeitha Owens Signature

_______________
Date

Acknowledgement of Policy and Procedures. Please Initial

_____ Session credits expire after 30 days unless you purchase a non-expiring session
_____There is a 24 hour Cancellation/Reschedule policy.
_____Please make sure your Skype ID is listed in your application and make sure you
adjust yours scheduling time around Central Standard time zone.

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