INFORMATION, AUTHORIZATION, AND CONSENT TO TREATMENT
Welcome! I am very pleased that you have selected me to be your therapist and I am sincerely looking forward to assisting you. This document is designed to inform you about my policies and what you can expect from me regarding therapy, confidentiality, emergencies, and several other details regarding your treatment. Although these documents are often long and complex, it is very important that you understand them. If you have any questions regarding these or any other aspects of your psychotherapy, please feel free to bring them up to me at any time. When you sign this document, it will represent an agreement between us.
I, Michelle Panzarella, LCSW, MA, am a licensed clinical social worker in the state of Georgia. I have two Master's degrees, one is a Master's in Social Work from the University of Georgia and the other is a Master's degree in Clinical Psychology from the California School of Professional Psychology (now Argosy University). I have extensive experience working with individuals, children, adolescents, and families. I have worked with clients experiencing a variety of emotional &/or mental health problems including, but not limited to, anxiety, fears, depression, grief, ADHD and other learning deficits, family of origin issues, trauma, parenting problems, communication difficulties, addiction, work related matters, relationship troubles, LGBTQ and other "lifestyle" issues. I use a variety of treatment modalities (dependent upon my assessment of the client and their needs) including behavioral modification, cognitive therapy techniques, psychodynamic, play therapy, family systems counseling, parent and patient education, and grief counseling.
Psychotherapy is a relationship between the client(s) and therapist to work on client-specific goals usually related to the client's emotional and mental health, crisis, and/or relationship issues. Psychotherapy has both risks and benefits. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anger, frustration, loneliness, helplessness, etc. because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been proven to have many benefits for clients. These benefits may include improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Other benefits might include: a significant decrease in uncomfortable feelings and an increase in positive emotions, higher self-esteem, greater personal awareness and insight, and increased skills such as managing stress and improving communication. However, there are no guarantees about what any individual client may experience. Psychotherapy requires a very active effort and honesty on your part and to be most successful, you will have to work on things we discuss outside of sessions.
I offer both traditional in-office therapy and a variety of online and/or distance therapy formats. You will be interviewed and may be asked to fill out some questionnaires to assist me in determining how best to help you. Treatment usually involves individual meetings with the therapist, but may also include group treatment and/or involve family members or significant others in some sessions. All treatment will be conducted only with your consent.
During the initial intake process and the first couple of sessions, I will assess if I can be of benefit to you. If you have requested online counseling or phone sessions, my assessment will include your suitability to psychotherapy delivered via such devices. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you potential referrals
to contact. If during the process of psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I am obligated to discuss this with you up to and including termination of treatment. In such an event, I would provide you with referrals that may be able to help you. If you request and provide written authorization, I will talk to the psychotherapist of your choosing in order to help with the transition. If, at any time, you want another professional's opinion or wish to consult with another therapist, I will help you find someone qualified and, if you provide written consent, I will give him or her the essential information needed. You have the right to terminate therapy at any time. If you choose to terminate and want a new therapist, I will provide you with referrals if you need or want them. Appointments and Fees: Appointment sessions will ordinarily be 45-50 minutes in length, once per week at an agreed-upon time, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is for you and you alone. If you need to cancel or reschedule, I ask that you provide me no less than 24 hours notice. The first-time cancellation is free; second and subsequent cancellations will cost the full fee so please do YOUR BEST and cancel in ADVANCE. Instead of canceling, a phone or online session is encouraged. Fees for phone or online sessions are the same as in-person sessions. Additionally, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. Payment must be made by cash, check, debit /credit card, or online via Electronic Payment. Payment is expected at the time of service. I do not accept health insurance but some clients do submit claims to their provider as an "out-of-network" provider. If you do this, please discuss it with me further so I may give you the necessary receipts and information.
** Sliding Scale Patients: Your fees are based on income and are subject to change (all changes will be provided in writing). Clients must provide proof of income and are required to sign a separate "Sliding Scale & Fee Agreement" form.
Confidentiality: What you discuss with me, your therapist, is kept confidential with the following exceptions: 1) you direct me to communicate with someone else and you sign a "Release of Information" form; 2) I assess that you are a danger to yourself or others; 3) you report information about the abuse of a child, elderly person, or disabled individual who may require protection; or 4) I am ordered by a judge to disclose information. For additional information, see the HIPAA form Notice of Privacy Practices form which provides details about how your private healthcare information is protected and under what circumstances it may be shared. Confidentiality of Online, Cell Phone, Text, Email, & Chat: 1) If you choose to email me from your personal email account, please limit the contents to pragmatic issues such as scheduling your session or change in content information and I will do the same. I will NOT respond to personal and clinical concerns via regular email in the interest of protecting your privacy. 2) If you choose to call me, please be aware that unless we are both on landline phones, the conversation may not be secure and there is risk involved. I do use text messaging for scheduling purposes and will text you to determine appointment times. If this is not convenient for you and you would like appointments scheduled in an alternative way, please let me know. Please do not bring up any therapeutic content via text to prevent compromising your confidentiality. I do store your name in my cell phone but it does not identify you as a client and my phone is password protected. 3) If using audio/ video systems for psychotherapy, you understand that although there can be benefits from "distance counseling" (using technology for psychotherapy purposes), the results cannot be guaranteed or assured. Also, by signing this document, you understand that the use of Skype, Facetime, GoToMeeting, and Google audio/visual/chat systems are not 100% secure and may have issues with Wifi connectivity. If you use any of these, you are doing so at your own risk, and TGIF Counseling, LLC will not be held liable. Your therapist prefers to use www.doxy.me as a secure teleconferencing system and will give you that login information. However, if technology problems occur, we may have to use telephone or other systems as a backup plan but only if you agree to do so; if not, we will reschedule the session.
I do not accept requests from clients on social networking sites such as Facebook or LinkedIn because it may compromise your confidentiality. I do have a professional page for TGIF Counseling, LLC but anything you post or message there is also not confidential. My ethics code prevents me from soliciting endorsements from clients and I do not have "fans" as that may be construed as possible solicitation. However, it is still your prerogative to view or share any content on my professional page.
I make every effort to keep all information confidential by using passwords and encryption. Likewise, if we are working online together, I ask that you determine who has access to your computer/device and electronic information from your location. This would include family members, coworkers, supervisors, and/or friends. I encourage you to only communicate through a computer/device that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails. If you are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, please email or text me to schedule a new session time.
If you are involved in distance counseling with me, you as the client understand that such counseling (i.e. via phone, email, webcam) is a different experience as compared to in-person sessions. The differences include the lack of "personal" face-to-face interactions, the lack of visual and/or audio cues in the therapy process, and the fact that most insurance companies do not cover this type of therapy. You understand that telephone/online psychotherapy is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated below, if a life-threatening crisis should occur, you agree to contact a crisis line, 9-1-1, or go to a hospital emergency room. You also understand that I, your therapist, am a licensed clinical social worker in the State of Georgia (USA) and follow the laws and professional regulations of this state and the counseling treatment will be considered to take place in the State of Georgia (USA).
Telephone & Emergency Procedures:
If you need to speak with me between sessions, please call 770-355-5610 or text me a brief message at this number to call you. Your call will be returned as soon as possible. Text messages and voicemails are checked daily; messages left after 6 pm will NOT be reviewed until 8 or 9 am the following day. Messages are checked less frequently on weekends, holidays, or if I'm on vacation. In the event of an emergency situation that requires immediate attention, you may call the Georgia Crisis and Access Line at 1-800-715-4225 or the National Suicide Prevention Lifeline at 1-800-273-8255 or dial 9-1-1. If a life-threatening crisis should occur, you agree to contact a crisis hotline in your area, call 9-1-1, or go to the nearest hospital emergency room.
Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that may impair the therapist's objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. In addition, I will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, I will preserve the integrity of our working relationship.
Your signature below indicates that you have read and understand this "Information, Authorization, and Consent to Treatment". Additionally, your signature indicates that you are over 18 years old and can initiate mental health treatment on your behalf. If you are under 18 years of age, you certify that the parent/guardian signature below is valid.
** We will discuss this form and information during our first session. If you have any questions, concerns or comments, please reach out to me via email at firstname.lastname@example.org