informed consent

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Marriage and Family Therapist

Monica Kelly is a Licensed Marriage and Family Therapist and upholds legal and ethical standards.

Education and Training Monica Kelly holds a M.S. Degree in Counseling from the California State University Fresno (2008).

She has received a hypnotherapy certification in Quantum Healing Hypnotherapy Treatment (Level 1 & 2 Certification). Monica has been a yoga instructor since 2000 and has practiced yoga since 1990. She is trained in Inyengar, Ananda Yoga (Level 1

Certification 200 hrs), and Thai Yoga Massage (Level 1 Certification). Monica has received a Level 1 Certification from Aleya

Dao for Energy Healing. Monica has also received certifications in Pilates Mat and Reformer and Personal Training. Energy

Psychology certification Aug 2014.

WHAT TO EXPECT

– BENEFITS AND RISKS

There are benefits and risks in seeking individual, marital or family therapy.

Some of the potential benefits of therapy include developing your ability to handle or cope with your relationships and providing you with greater insight into your personal goals and values. In working to achieve these benefits, however, you may address issues or make changes that you may experience as distressing. These risks of therapy include, but are not limited to: feelings or circumstances becoming worse before they get better; changes in your emotional state, such as feelings of depression or anxiety; the possibility of hallucinations or dissociations; changes in perception or behavior; and changes in occupational, social, or personal relationships.

Confidentiality

Confidentiality is an important element of the therapy/coaching process. Your identity and ongoing work will be kept strictly confidential . I will only release information about our work with your written permission. This therapist abides by HIPPA policies and a release would need to be signed if information is requested by a third party.

At times this therapy may ask to see individuals that are participating in couples or family counseling. In this case the therapist will KEEP CONFIDENCE if an individual decides to reveal information that they are not ready to reveal to their partner or other family members. This therapist will encourage the individual to express hidden information to family members, but in their own time or on their own terms. If the hidden information becomes counterproductive to therapy, the therapist may seek to terminate the relationship if the member is unwilling to communicate with their partner or family what is being hidden.

Minor who engage in the therapeutic process for individual counseling have the right confidentiality. Parents can generally ask for updates to progress but detailed information is not given to parents. This is to insure a level of trust between the minor and therapy for the therapeutic relationship.

Exceptions to Confidentiality The following are exceptions to confidentiality: There are a broad range of events that are reportable under child protection statutes. Physical or sexual abuse of a child will be reported to Child Protective

Services . When the victim of child abuse is age18 or younger, I am legally mandated to report it. Elder abuse is also required to be reported to the appropriate authorities. Or if you are at imminent risk to yourself or someone else or make threats of imminent violence against another person , I will take appropriate action.

Types of Treatment This therapist utilizes several treatment methods besides talk therapy. Other treatments may be suggested in combination with talk therapy for expedient growth. These include: relaxation therapy, bio-feedback device, hypnotherapy and mindful body movement (gentle yoga). Hypnosis is a deep state of relaxation in which your have access to your subconscious mind which can expedite healing. Regression sessions are recorded.

Notification of Appointments

I make a best effort to remind you of an appointment the day of appointment in the morning timeframe. I prefer to send you a reminder via TEXT MESSAGE and therefore will ask for your CELL PHONE number for communication purposes. I do not guarantee to send a text, depending on my appointment schedule and travel schedule, but I try my best.

CANCELLATION POLICY

The time for which your appointments are scheduled has been reserved for you. MY TIME IS VERY VALUABLE. IF I AM

AGREEING TO SEE YOU, I AM NOT ABLE TO SEE ANOTHER PERSON. You are required to give notice of cancellation at least 48 hours prior to a scheduled appointment. If you do not give 48-hour notice or fail to show for a scheduled appointment without prior notification, you will be given one warning. After that a cancelation fee of $50 will be billed.

Fees, Payment Schedule, and Services

2 hours – $180 1 hour of counseling and 1 hour of relaxation treatment

1.5 hours – $140 45 mins of counseling and 45 mins of relaxation treatment

1 hour

– $100 -

55 minutes for counseling or 15 min check-in, 45 min relaxation treatment

Some forms of Insurance and EAP (employee assistant programs) are accepted.

PAYMENT POLICY Payment in full is expected at the time of service, unless alternate arrangements are mutually agreed upon. Payment is accepted in the form of cash, check, Visa, Master Card, American Express and Discover. When making payment by check, please have your check written before the start of the session, whenever possible. All checks returned for non-sufficient funds (NSF) are subject to a $20 returned check fee.

You are responsible for making any payments due in a timely manner. If you anticipate difficulty in paying your balance, please discuss the situation with Monica Kelly and a repayment schedule that will not cause undue hardship for either party. Your account will be considered delinquent if a balance remains after two months from the date the fee is assessed. If your balance remains delinquent for more than four months and you have not attempted to make satisfactory arrangements with your therapist, the account will be considered defaulted. It may be forwarded to a collection agency and you will be responsible for all court costs, attorney fees, interest, and related damages or expenses associated with pursuing payment of the balance.

Letters to the Courts

You may request a letter of attendance to the court to verify your attendance in participation in therapy. There is a fee of $30 for an attendance letter. Personal reference letter are not given.

Emergency Situations

In the event of an emergency please call 911. I cannot guarantee that I will be able to service your call. It can take up to three business days to receive a return call to my business number. Therefore, call 911 or your local physician if you need urgent care.

Acknowledgment and Release of Liability

By signing this disclosure and consent statement, I acknowledge that I understand the above information. I agree to hold harmless Monica Kelly from all liabilities and claims, which may arise as a result of my participation in counseling.

_____________________________________

Signature of Client & Date

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Print Name / DATE

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Signature of Partner or Minor & Date

_____________________________________

Print Name/ DATE

_____________________________________ _____________________________________

Signature of Monica Kelly, LMFT DATE

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