8. Informed Consent Form


This document contains important information about the professional services and business policies for KW Counseling Services, LLC.  It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), which is a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) that is used for the purpose of treatment, payment, and health care operations. 

HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment, and health care operations.  The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail.  The law requires that I obtain your signature acknowledging that I have provided you with this information.  Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session.  We can discuss any questions you have about the procedures at that time. 

When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time.  That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. 


Psychotherapy varies depending on the personalities of the psychotherapist and client, and the particular problems you are experiencing.  There are many different methods I may use to deal with the problems that you hope to address.  Psychotherapy calls for an active effort on your part.  In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks.  Since therapy often involves discussing unpleasant aspects of your life.  You may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.  On the other hand, psychotherapy has also been shown to have many benefits.  Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.  But there are no guarantees of what you will experience. 

Our first few sessions will involve an evaluation of your needs.  By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy.  You should evaluate this information along with your own opinions of whether you feel comfortable working with me.  Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select.  If you have questions about my procedures, we should discuss them whenever they arise.  If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. 



I normally conduct an evaluation that will last from two to four sessions.  During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals.  If psychotherapy is begun, I will usually schedule a session of one appointment hour of 45 to 50 minutes duration at a time we agree on.  The frequency and duration for these sessions will be discussed with your input.  Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. Please refer to the Cancellation Policy.  It is important to note that insurance companies do not provide reimbursement for cancelled sessions.  If it is possible, I will try to find another time to reschedule the appointment. 



My hourly fee is $175 for the initial session and $150 for an individual session.  A family session is $150. A half session is $75; a group therapy session is $75 per group member.    



My phone number is 515-720-1544.  I am often not available because I am in session, or it is outside of my work hours.  You may leave a message on my voicemail.  If you have an emergency or become suicidal you must call 911 or go immediately to the emergency room.  KW Counseling Services, LLC is an outpatient private practice and not set up for emergency response. 



The law protects the privacy of all communications between a client and a mental health professional.  In most situations, I can only release information about your treatment to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA and/or Iowa law.  However, in the following situations, no authorization is required:

  • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client.  The other professionals are also legally bound to keep the information confidential.  If you do not object, I will not tell you about these consultations unless I feel that it is important to out work together.  I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychotherapist’s Policies and Practices to Protect the Privacy of Your Health Information).
  • I have contracts with other services, including billing and record keeping. As required by HIPAA, I have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law.  If you wish, I can provide you with the names of these organizations and/or a blank copy of this contract. 
  • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
  • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
  • If you are involved in a court proceeding and a request is made for information concerning the professional services I provided, such information is protected by the psychotherapist-client privilege law. I cannot provide any information without your written authorization, or a court order.  If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
  • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
  • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
  • If a client files a worker's compensation claim, I must, upon appropriate request, provide any information concerning the employee's physical or mental condition relative to the claim.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client's treatment. These situations are unusual in my practice.

  • If I have reasonable cause to believe that a child I have provided professional services to has been abused or if I suspect that a dependent adult has been abused, the law requires that I file a report with the appropriate government agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional information.
  • If a client communicates an imminent threat of serious physical harm to an identifiable victim, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.
  • If a client communicates an imminent threat of serious physical harm to him/herself, I may be required to disclose information in order to take protective actions. These actions may include initiating hospitalization or contacting family members or others who can assist in providing protection.

If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.




You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others or makes reference to another person (unless-such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person or where information has been supplied to me by others confidentially, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form.  If I refuse your request for access to your Clinical Records, you have a right of review except for information supplied to me confidentially by others, which I will discuss with you upon request.

In addition, I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. They also may include information from others provided to me confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.




HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.




Clients under eighteen years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, I will not share detailed information with parents about their child’s psychotherapy.  The exception would be if the minor is participating in something unhealthy or participating in something that is a threat to their safety or the safety of others. 




You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.




It is important to remember that you always have the right to pay for my services yourself to avoid the problems described below. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. If you have questions about the coverage, call your plan administrator. It is sometimes difficult to determine exactly how much mental health coverage is available. "Managed Health Care" plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance ben fits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.  You should also be aware that your contract with your health insurance company requires that you authorize me to provide it with information relevant to the services that I provide to you. If you are seeking reimbursement for services under your health insurance policy, you will be required to sign an authorization form that allows me to provide such information. I am required to provide a clinical diagnosis. Sometimes, I will be requested to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. This may require an additional authorization. (If you refuse such authorization, the insurance company can deny your claims and you will be responsible for paying for services yourself.) In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.  Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.


*I am not currently accepting new clients but can add you to our waiting list. 


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