This form provides you with information that is in addition to that detailed in the Notice of Privacy Practices.

Informed Consent for Counseling Services

1. Nature of Counseling

Counseling is a collaborative process between you and your therapist designed to support emotional well-being, personal growth, and achievement of life goals.

Therapy may involve discussing difficult emotions, experiences, and relationships. While many clients benefit from counseling, results are not guaranteed, and progress varies by individual.

South Texas Counseling Agency (STCA):

• Does not provide legal advice
• Does not conduct custody evaluations
• Does not prescribe medication

2. Appointments & Time Parameters

• Standard sessions are 45–50 minutes.
• If you arrive more than 15 minutes late, your session may be shortened or rescheduled.

3. Confidentiality & Limits of Confidentiality

Your privacy is protected under Texas law and HIPAA. However, confidentiality has limits.

Confidential information may be disclosed without your consent in the following situations:

Mandatory Disclosures

• Risk of harm to yourself or others
• Suspected abuse or neglect of a child, elderly person, disabled person, or vulnerable individual
• Court order, subpoena, or other legal requirement
• Insurance billing purposes, if applicable
• Professional consultation or clinical supervision

If disclosure is required, only the minimum necessary information will be shared, and we will attempt to discuss the matter with you when appropriate.

Minors

• Parents or legal guardians may have access to records.
• Both parents may be required to consent depending on custody status, legal authority, and agency policy.

Public Encounters

If a staff member from STCA, either your therapist or any other staff member, happens to encounter you outside of the professional setting, we will not address you unless you address us first. This is for the protection of your privacy and to respect professional boundaries. We are happy to return a friendly greeting but will wait for you to take the initiative. Even if you initiate the interaction, we will not reference that you are or ever have been a client.

Electronic Communication

Email and text messaging are not fully secure and are used for scheduling and administrative purposes only unless otherwise specifically agreed. Clinical matters should be discussed during session or by phone when appropriate.

4. Risks of Counseling

Therapy may involve emotional discomfort, temporary worsening of symptoms, and major life decisions. You are encouraged to discuss any concerns, assumptions, or possible negative effects of treatment with your therapist.

5. No-Show & Cancellation Policy

A minimum of 24 hours’ notice is required to cancel or reschedule an appointment.

Late cancellations and missed appointments will result in a $135 late cancellation/no-show fee.

• This fee is not billable to insurance.
• This fee will be charged to the card on file.
• This policy does not apply to Medicaid clients.

Repeated missed appointments may result in same-day scheduling only or termination of services.

6. Emergencies & Crisis Services

South Texas Counseling Agency is not a crisis or emergency service provider.

If an emergency situation for which you feel immediate attention is necessary arises, please contact:

• Emergency services (911) immediately
• The 24-hour MHMRA Helpline at 800-289-7000
• Psychiatric Emergency Service located at 2102 W. Trenton Rd, Edinburg, Texas (24/7 walk-ins)
• Your nearest hospital emergency room

Keep in mind that while your therapist may be in the office, they do not answer the phone while in session with a client. Messages are generally returned within 12–24 business hours.

Please do not use email, text messaging, or fax for emergencies.

If your therapist becomes concerned about your personal safety, the possibility of you injuring someone else, or your need for proper psychiatric care, they may do whatever is reasonably necessary, within the limits of the law, to help protect you or others and to help ensure that you receive appropriate care. This may include contacting emergency services, notifying appropriate individuals, or facilitating hospitalization if necessary.

If your therapist will be unavailable for an extended period of time, you may be provided with the name of a colleague or alternate contact for continuity of care if appropriate.

7. Fees, Payment & Financial Responsibility

Payment is due at the time of service.

Accepted forms of payment may include major credit or debit cards and other forms approved by STCA.

You agree that a valid credit or debit card must be kept on file and that charges may be processed automatically for authorized services and fees.

Additional services that may incur charges include, but are not limited to, letters, reports, treatment summaries, record review, consultation with other professionals, extended sessions, phone consultations, travel time, and other administrative or professional services not included in the standard session fee.

Fees for services are discussed prior to the start of treatment and are further outlined in the Financial Policy Agreement, which may be signed separately.

Fees are subject to change with appropriate notice.

You are responsible for all charges not covered by insurance.

8. Insurance & Confidentiality of Records

Insurance billing is provided as a courtesy when applicable.

You are responsible for verifying your benefits, understanding your deductible, copay, coinsurance, authorization requirements, and payment responsibilities for denied or non-covered services.

If you choose to use insurance or an Employee Assistance Program (EAP), STCA may be required to provide information such as diagnosis, dates of service, type of treatment, and other information reasonably requested for payment or utilization review.

STCA does not control how insurance companies, EAPs, or other third-party payers store, review, use, or disclose the information submitted to them. You understand that submitting a mental health claim may carry some risk to confidentiality or privacy and could affect future insurance-related decisions.

Professional services are rendered to and charged to the client, not the insurance company, and you remain financially responsible for all charges.

9. Consultation & Supervision

Information about your case may be discussed in confidence, without unnecessarily revealing your identity, with other counseling professionals for the purpose of consultation and providing you with the best possible service.

If your therapist is an associate, intern, supervisee, or otherwise practicing under supervision, your case may be reviewed on a regularly scheduled basis with the therapist’s clinical supervisor. Supervisors are also required to maintain confidentiality.

Supervisor Name (if applicable): __________________________________

10. Electronic Transmission

STCA cannot guarantee the confidentiality of any form of communication through electronic media. Email, text, portals, workplace devices, and similar technologies may be accessed by third parties, including employers, service providers, or others.

Email and texting are intended for scheduling and administrative communication only. Clinical matters should not be discussed through these methods unless specifically arranged. Messages may not be reviewed immediately, and STCA does not guarantee same-day response.

11. Records & Documentation

STCA is required by law and professional standards to maintain records of services provided. These records may include a brief synopsis of sessions or phone contacts, observations, treatment planning, billing information, and other clinically relevant documentation.

If insurance is used, a diagnosis may be required for billing purposes.

Records may be subpoenaed, requested by court order, or otherwise required by law, and STCA must comply when legally obligated to do so.

If records are requested, STCA may provide an appropriate summary when clinically or legally appropriate, as full records can sometimes be misinterpreted outside the therapeutic context. Applicable fees may apply for preparation, copying, review, or release of records.

12. Children & Minor Clients

If you are a parent or legal guardian consenting to treatment for a minor, by signing this Agreement you affirm that you have the legal authority to consent to treatment for the child and that no court order, custody order, divorce decree, or other legal restriction limits your ability to do so.

If parents are divorced, separated, or were never married, STCA may require both parents’ consent and may require review of the applicable court order or decree before services begin.

Children may not be left unattended in the waiting area. STCA does not provide childcare while a parent or guardian is in session.

13. Court & Legal Involvement

STCA does not provide custody evaluations, legal opinions, or routine court-related services.

If STCA or a therapist becomes involved in legal proceedings, whether by subpoena, court order, attorney request, records request, deposition, consultation, testimony, or other legal process, fees may apply for time spent preparing, reviewing records, traveling, waiting, consulting, testifying, or otherwise responding.

STCA will comply with lawfully issued subpoenas and court orders as required by law. If legally compelled involvement occurs, the client may be financially responsible for the time and expense required to respond, consistent with the applicable financial policy.

14. Termination of Services

You have the right to terminate therapy at any time.

If at any time you want another professional’s opinion or wish to consult with another therapist, STCA will assist you in finding someone qualified, and with your written consent, may provide that professional with essential information needed for continuity of care.

STCA may terminate services for repeated missed appointments, non-payment or unresolved balances, failure to comply with agreed treatment expectations, or when services are no longer clinically appropriate. Referrals may be provided when appropriate.

15. Contacting Your Therapist

Other than session attendance and authorized administrative communication, the primary way to contact your therapist is through the office phone system.

Office hours vary, and therapists are often not immediately available by phone. Calls are generally returned within 12–24 business hours.

To receive a return call, you must leave your name and phone number on voicemail. Caller ID alone may not be sufficient to identify or return your call.

If your therapist conducts a therapy session by phone, private-pay fees or other agreed charges may apply.

If you experience a mental health emergency and your therapist is unavailable by telephone, you should use the emergency resources listed in the Emergency section of this document.

16. Use of Electronic Communications

Email and text messaging are for scheduling and administrative matters only. STCA does not use email or text with clients for clinical discussions because confidentiality and security cannot be guaranteed.

If you need to discuss a clinical matter between sessions, please call the office or your therapist’s office number and make appropriate arrangements.

17. Social Media Policy

STCA and its therapists do not engage in communication or relationships with clients through social media. This protects your confidentiality, professional boundaries, and the integrity of the therapeutic relationship.

STCA and its therapists will not accept friend requests, direct-message with clients, comment on client-related matters, or post anything about or with current or former clients through social media.

You are welcome to follow public STCA pages and share public-facing posts, such as announcements, events, or educational information, but you should not expect direct interaction regarding your care through social media platforms.

18. Complaints & Grievances

We hope that you will discuss any dissatisfaction with your therapist’s services directly with your therapist when possible. STCA staff are committed to addressing concerns professionally and respectfully.

If your concerns are not resolved, you may request to speak with the Clinical Director. You also have the right to file a complaint with the applicable licensing board or regulatory authority. Contact information may be available in the office or provided upon request.

You will not be penalized or retaliated against for raising concerns or filing a complaint.

Client Acknowledgment & Consent

By signing below, you acknowledge that you have read, understood, agree to, and consent to the above conditions of service. You also acknowledge that you have received the Notice of Privacy Practices and have had the opportunity to ask questions and understand these policies.