Patient Information Form
Informed Consent and Procedures
Dr. Sparrow's Counseling Services
Supporting Your Courage to Heal and to Grow
© 2020 Dr. G. Scott Sparrow
Please check the boxes following the statements below. Completing and submitting this form is required before Dr. Sparrow can provide any services.
Confidentiality and its Exceptions. Everything that you share with me will remain strictly confidential, with the exception of the following circumstances: *If a client discloses an incident of child abuse that has not been reported to the state authorities, I must report it; *If a client reports an incident of the abuse of an elderly or disabled person, I must report it; *if a client is a danger to himself or herself, or to someone else, I am permitted by state law to inform the appropriate law enforcement agency. *If my records and notes are subpoenaed, I may be required to submit them.
Insurance and Diagnoses. If you use insurance, your carrier may require periodic treatment reports that will be evaluated by a case manager(s). While these reports are unavailable to others, they can be subpoenaed. Also, I will need to assign a diagnosis that will become part of your insurance and case record. The diagnosis may change as I obtain additional information over the course of my work with you. I am happy to discuss the diagnosis that I believe is appropriate, and you have every right to inquire about it at any time.
The Benefits and Risks of Counseling Individual Therapy. While counseling may help you resolve immediate and longstanding problems, it is also important to acknowledge that counseling can stir up feelings and memories that can prove upsetting to you. Before beginning this process, it is important to ask yourself if you’re ready to embark on a meaningful journey that can, at times, upset you and challenge you. Relationship Therapy. If I counsel you one-on-one, you and you alone are my client. Consequently, I strive to support your autonomy and self-determination, and endeavor to assist you in coming up with solutions for yourself. Because the focus in on you, if you are in a relationship and the relationship is a significant source of stress in your life, individual counseling may support your individual goals at the expense of the relationship. Therefore, if your primary goal is to improve and preserve the relationship, I recommend that you choose conjoint or marital therapy, rather than individual therapy. If you partner is unwilling to participate, it’s important for you to let him or her know that individual therapy alone may not help the relationship, even though I always endeavor to keep the focus on my clients, and to avoid making statements about people I do not know, and who are not my clients
Termination of Services. I am committed to providing services to you only as long as it is helpful to you. Regardless, you are free to terminate services at any time. I will endeavor to work with you to find another therapist if you still need counseling once you terminate services with me.
Making Appointments. You can make appointments by going to my website at www.drscottsparrow.com, and clicking on the online calendar. Once you schedule an appointment, I will be notified via email, and will make contact with you. Or you may call me (956) 309-3730 to schedule or reschedule appointments. If you get my voicemail, please leave clear details about when you want me to call, and whether calling your home or office number is something you would like us to avoid doing for privacy reasons. Either Julie (office manager) or I will return your call.
Cancellation of Appointments. Late-notice cancellations and cancellations without notice are costly, so I request 24 hours of notice for cancellation, in order to have time to fill the hour with another client. Our online appointment calendar sends out reminders 24 hours in advance of your appointments. Thank you for respecting this request. For cancellations without notice, I have established the following policy: You must agree to pay $50 for any cancellation without notice at the time of your next appointment.
Urgent Issues. When I go out of town for more than a couple of days, I monitor my phone calls and emails, and will respond to urgent issues within the same day. Dr. JoAnn Mitchell, at 956-627-3738, may also be available during my extended absences. However, If you are in crisis, and cannot wait, please call 911 or go to the nearest emergency room.
Complaints. If you ever have a complaint about my services, you should contact the Texas State Board of Examiners of Professional Counselors. By Mail: Customer Service Representative, 1100 W. 49th Street, Austin, Texas 78756. By Phone: (512) 458-7111 or 1-888-963-7111; TDD (512) 458-7708 or 1-800-735-2989.
Billing. If you have insurance, we will submit claims on your behalf, and it is our responsibility to do so if Dr. Sparrow is in-network with your insurance company. We will obtain information regarding the amount that you are supposed to pay, but we cannot guarantee the accuracy of this estimate. Ultimatley, you are responsible researching your coverage benefits, and will be responsible for any part of Dr. Sparrow's fee not paid by your insurance company.
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