Consultation Agreement
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I am a Licensed Clinical Professional Counselor, KS#2430 with of M.A. in
Counseling & Guidance.
Consultation Style
 My job is to listen; explore your experience with you; and provide feedback for you to
consider. Please let me know if you have questions or preferences along the way.
 My approach to therapy is influenced by the Interpersonal Process Approach (Ed
Tyber). This approach integrates Psychodynamic, Cognitive Behavioral, Attachment,
and Family Systems theories into a comprehensive theory. I also use Narrative
Therapy (White and Epston). I may apply additional counseling theories and
techniques as needed.
 Each appointment is 45 minutes.
Risks and Benefits of Consultation
 Therapy benefits the majority of people who go through it. It often leads to better
relationships, solutions to specific problems, and reduced distress.
 Sometimes therapy explores unpleasant experiences. At times, you may experience
uncomfortable feelings like sadness, anger, and frustration. Growth and change can
be difficult. Please notify me if these experiences are persistent and/or
overwhelming.
 I believe that honest communication, self-exploration, and follow-through with
therapeutic goals produce the quickest results. At the same time, our consultations
should progress at a rate and intensity in which you feel safe and comfortable.
Confidentiality
Confidentiality is an essential component of my work. I cannot share your personal
information unless you sign a Release of Information form. Some exceptions are
required by law and ethical guidelines. Exceptions are:
 Suicidal or Homicidal Intent. If I believe that someone's life is at risk, I am required
to take protective actions. These actions may include contacting people who may
help provide protection, seeking hospitalization for you, or notifying a potential
victim.
 Child/Vulnerable Adult Abuse or Neglect. If I believe you are abusing or neglecting a
child or vulnerable adult, I must file a report with the appropriate state agency. I will
make every effort to inform you of this decision and invite you to listen to the call or
read the report.
 Court Orders. In most legal proceedings, you have the right to prevent counselors
from providing information about our counseling meetings. In some proceedings, a
judge may order my testimony if the specific legal issues demand it. Please let me
know if you have questions about court orders.
 Therapist Consultation. If I have questions or concerns about our counseling
sessions, I consult with another therapist, Jim Kreider, LSCSW. Jim is also
responsible to follow professional confidentiality guidelines.
 HIPAA Guidelines (Health Insurance Companies & Business Associates). Pease
review the provided HIPPA Notice for information about these laws.
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Consultation Records
 I maintain a file for each person or group I consult with. This file includes your
Consultation Agreement, Client Information Sheet, Progress Notes, and Treatment
Plan. Depending on the situation, your file may include correspondence between us
and Release(s) of Information.
 You have the right to review your file. You can review it in session or you may
schedule an additional time. If you schedule an additional time or require extra
copies of documents, I bill you for these services.
Phone and/or Email Contact
 Please do not contact me in between appointments unless:
o you want to cancel or reschedule an appointment; or
o we have developed a specific contact agreement.
 Although I follow HIPAA and other confidentiality guidelines, I am unable to
completely eliminate potential unauthorized access of electronic or phone
communications.
 I check email and phone messages about once a day. Whenever possible, I will return
your message within 24 hours. However, I am unable to return your call until I am in
a confidential space.
Scheduling
 Please minimize any rescheduling/cancellations and provide me 2 days notification.
 I charge $40 for appointments cancelled with less than 2 days notice.
Payment
 My fee is $80/hour. I reserve 3 times a week for reduced fees appointments.
 If you want to use health insurance to pay for appointments, I will need to copy your
health card and verify eligibility and benefits information.
 I prefer cash or check payments. I can also accept Visa, MasterCard, American
Express, and Discover cards.
Completion of Service
 My anticipated length of service depends on your preferences, problems, and goals.
By the end of the second meeting, we will design a Treatment Plan, with projected
completion dates. We can alter this plan as needed.
 I will close your file and consider services complete: 1) on a mutually agreed-upon
date or 2) 30 days after the last attended appointment.
 You may terminate services with me at any time for any reason.
I understand and agree to all the information and policies listed on this Consultation
Agreement.
_______________________ ______________________ ______________
Printed Name(s)
Signature(s)
Julia Schafermeyer, LCPC
julia@juliacounseling.com
phone: 785-550-4867 • fax: 913-789-0828
Date