Online/Telephone Counseling Agreement

The following document is to inform you about online counseling services, and to ask for your permission to enter into a professional therapeutic relationship with you. This document is not a binding contract that demands you to continue services for any length of time. Please note, that I am only licensed in the state of Texas to conduct counseling therefore; you must be a Texas resident to receive counseling services from me. If the counseling recipient is under the age of 18 or the adult counseling recipient has relinquished guardianship due to any reason, then the legal guardian along with the primary recipient must sign below. Feel free to contact me about any questions you may have about this form (210) 245-2579 or E-mail: sanchezq@prodigy.net. Therapy is a relationship between Client and counselor defined by responsibilities and rights from each party. The Client is responsible for participating in and attending all scheduled sessions. The counselor must follow Licensing guidelines and provide therapeutic services with the best interest of the client in mind and adhere to ethical standards of the Professional Counselors license.

Consumers Rights, Risks and Responsibilities I understand that Quinto Sanchez will be providing therapeutic counseling as a Texas Board Certified Licensed Professional Counselor (LPC) via telecommunication devices such as: Skype, chat, electronic mail, standard telephone connection, and/or other online software and technology. I agree as the recipient of these counseling services to have the technological means and awareness required for online or telephone counseling. I agree to fulfill my responsibility of attending sessions on a regular basis, complete self-therapeutic activities or assignments determined by the counselor and I. I understand that the nature of counseling requires me to answer questions and ponder feelings and thoughts that might make me feel uncomfortable at times but, are necessary in order to find healing. I am aware that I have the right to cancel these counseling services at anytime. If you have any concerns or are not satisfied with my services please let me know, that we may mutually come to an agreement to resolve the matter. In the unlikely case that we are not able to resolve a serious complaint that you might have against me; you can contact the Texas State Licensing Board of Professional Counselors to make a formal complaint at (512) 834-6658.

Emergency numbers In the case of a crisis, where my counselor is not available I am to contact 911 or the nearest emergency room. I can also call the 24 hour Crisis hotline at 1 (800) 273-8255 (TALK). For victims of sexual assault you can call 1 (800) 656-4673 (HOPE) Counselors Rights and Responsibilities I Quinto Sanchez as your professional counselor agree to treat you with the utmost respect, providing professional counseling services. I agree to use advanced psychological and counseling skills to meet your determined goal for your greater well being. I have a Masters degree in Community Counseling from the University of Texas at San Antonio and will do my very best to assist you with your presenting concerns. My goal is to empower you to find your own solutions to your greatest issues which is contrary to a general belief that counselors have all the answers and we are to simply give you advice. By simply giving you advice I would not be empowering you. That would only lead you to a greater dependency on me. I want you to excel even when Im not around. It is crucial that you help me help you. You can only get as much out of counseling as you put into it. I will most likely ask you to complete assignments that I feel would assist you and it is important that you complete them. I reserve the right to discontinue services and refer you to another counselor or agency if I feel that our counseling relationship is no longer a benefit to you, or if you are not complying with your responsibilities as the recipient of these services.

My Approach to Counseling There are several counseling tools and theories available for therapist to use. I try to fit the best counseling method for the specific individual. I do tend to lean more towards Cognitive Behavior Therapy which is a therapy that focuses on identifying irrational and self-defeating thoughts and replacing them with thoughts that can lead you to a more stable and productive life according to your goals. Im not afraid to be creative whenever necessary. It is common at times with any counselor that their own personality and perspectives may show up on occasion within the counseling process. My personal character is influenced by Christian principles and having a sense of humor when appropriate. My whole intention is to help you the best I can because, I care.

Duties and Limitations of Confidentiality

I am required to keep what we speak of in session confidential. While it is rare and unlikely, you must understand that telecommunication is less confidential because it can be hacked by another individual, e-mails and phone calls could be intercepted, or flawed software glitches can expose information. I will do everything on my end to insure that never happens, and I trust that you would do the same on your end. I am not permitted to give information about specifics of what you have told me or even if you are receiving counseling services, to a family member or to any third party without your written consent. However, by law, I must report or notify the proper authorities or a family member based on the following reasons: 1. The intention to commit suicide 2. The intention to harm someone else 3. If summoned by a court of law Be assured, that in the instance that I were required to give out your information I would only give what is necessary. Your trust is very important to me.

MISSED Sessions AND CANCELATIONS Our sessions will be 45 minutes long. The frequency of sessions will be agreed upon by the counseling recipient and the counselor determined by various factors. After two consecutive no shows your services will be canceled Counseling recipients are required to contact their counselor a minimum of 24-hours in advance to cancel or reschedule their appointment. Frequent cancelations may result in your services being canceled Counseling recipients will be charged for no shows and late cancelations This policy will be enforced to insure that those dedicated to seeking counseling can be served. I hope you have a wonderful and enlightening experience here with Foundational Healing Counseling Services.

Payment Policy All participants signed up to receive counseling services will be given the first session free of charge. Session fees and any additional fees must be received using Pay Pal before the session or action begins. A session fee is $75 unless otherwise negotiated. Additional fees include late cancelation $10, no show $15, report writing$10 and if requested to attend legal matters regarding your emotional health (to be determined). All financial transactions will be made using Pay Pal. Pay Pal is a secure online third party payment service used by several online companies such as E-Bay and Amazon. Pay Pal gives you the option to pay using your bank account or through a credit card. For further information on Pay Pal services or to create an account with them please visit their website WWW.paypal.com.

I ________________________ (type or print name) have read and understand the terms and conditions explained above. I have been given the opportunity to ask any questions about this consent form. I agree to receive online counseling services from Quinto Sanchez M.A, LPC

Counseling recipients Signature _________________________ Date ____________________ Legal Guardian (if applicable) _________________________