Dignity Women’s Center
Amber N. Pilkington, M.Psy., LPC, CART
4499 Medical Drive #151 A
San Antonio, Tx 78229
CELL: 210.241.0020 WK: 210.593.4392| FAX: 210.593.0152
amber.pilkington@gmail.com | www.dignitywomenscenter.com
PROFESSIONAL DISCLOSURE STATEMENT & INFORMED CONSENT
Qualifications: I am a licensed professional counselor (LPC) in the state of Texas. I graduated Summa Cum Laude with a
Bachelor of Arts from the University of St. Thomas with a double major in Psychology and Catholic Studies and a double minor in
Theology and Philosophy. I then received a Master of Psychology from the University of Dallas. I have worked at Menninger
Specialty Psychiatric Hospital in Houston, Tx (a top 10 psychiatric hospital in the nation) as a Mental Health Counselor, at
Timberlawn Psychiatric Hospital as a staff therapist on the inpatient trauma unit, at Immaculate Conception Catholic Church in
Denton, Tx as a staff therapist, and now at Dignity Women’s Center as a staff therapist. I have also received training from Teresa
Burke, Ph.D. in post-abortion counseling. I have also published a book review in The Humanistic Psychologist, an American
Psychological Association journal. I continue to keep my license current with continuing education in ethics and other topic of
interest.
Nature of Counseling: My belief is that the counseling process is a collaborative partnership between therapist and client(s).
Working together, we will explore current concerns and develop goals which are measurable and realistic. It is important to
realize that it will be difficult to achieve progress in counseling if you are unable or unwilling to complete homework assignments,
arrive to appointments on time, or be completely honest with your therapist always bringing up your thoughts and concerns. I am
an existential phenomenologist and focus on issues of meaning. I also utilize a significant amount of Cognitive Behavioral
Therapy and Dialectical Behavior Therapy. I work with my clients to integrate their own concerns about spirituality and am a
member of the American Association of Christian Counselors and Catholic Therapists, thus upholding their ethical statements.
Please initial indicating that you have read and understand the above section: _______
Counseling Relationship: Although our sessions may be very intimate psychologically, ours is a professional relationship rather
than a social one. Our contact will be limited to counseling sessions you arrange with me. I cannot be invited to social gatherings,
receive gifts, write references for you, or relate to you in any way other than the professional context of our counseling sessions. I
highly value our professional relationship and am confident that you will be best served if our sessions concentrate exclusively on
your personal concerns.
Please initial indicating that you have read and understand the above section: ______
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Effects of Counseling: At any time, you may initiate a discussion of possible positive or negative effects of entering, not
entering, continuing, or discontinuing counseling. While benefits are expected from counseling, specific results are not
guaranteed. Counseling is a personal exploration and may lead to major changes in your perspectives and decisions. Some of
these changes could be temporarily distressing. I ask that if you are concerned about anything you are experiencing as part the
counseling process, you please initiate a discussion with me immediately. The exact nature of changes within yourself cannot be
predicted. Together we will work to achieve the best possible results for you.
Please initial indicating that you have read and understand the above section: _______
Client Rights: Some clients need only a few counseling sessions to achieve their goals; other may require months or even years
of counseling. As a client, you are in complete control and may end our counseling relationship at any time. You also have the
right to refuse or discuss modifications of any of my counseling techniques that you believe may be helpful to you.
I assure you that my services will be rendered in a professional manner consistent with accepted legal and ethical standards. If at
any time you are dissatisfied with my services, please let me know. If I am unable to resolve your concerns, you may report your
complaints to the Texas State Board of Examiners of Professional Counselors at 1-800-942-5540
Please initial indicating that you have read and understand the above section: _______
Postponement and Termination: I reserve the right to postpone and/or terminate counseling of clients who come to their
session appearing under the influence of alcohol or drugs. I also reserve the right to discontinue counseling of clients who do not
comply with the medication recommendations of their psychiatrist or doctor. If at any time, I assess that you are no longer
benefiting from our counseling relationship, I have the right to terminate our relationship after first discussing my assessment with
you.
Please initial indicating that you have read and understand the above section: _______
Appointments, Cancellation and Crises: Counseling sessions last 45-50 minutes. In the event that you cannot keep your
scheduled appointment, please notify me at least 24 hours in advance. If you do not cancel your appointment at least 24 hours
prior to your appointment time or do not show for a scheduled appointment you will be billed $90. Messages may be left for me
on my voicemail. In respect to our clients, clients arriving late for a session will receive their normal appointment slot and will be
responsible for the full fee. 15 minutes is the customary time I will wait for a client. I do not provide 24 hour crisis counseling.
Should you need immediate mental health attention, you should call 911 or go to your nearest emergency room.
Please initial indicating that you have read and understand the above section: _______
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Fees: In return for a fee of $90 per session, I agree to provide counseling services to you. The fee for each session must be paid
in full at the time services are rendered. Cash, personal checks made out to “Dignity Women’s Center”, and credit cards are
accepted. If a check is returned, you will be billed a processing fee of $25. After a returned check, I reserve the right to require
cash for future sessions. I do not file for reimbursement from health insurance companies. However, I am an out of network
provider. If requested, I will provide you with a receipt which you may submit to your insurance company for reimbursement. It is
your responsibility to educate yourself on your insurance’s policies related to out of network benefits. If a claim you file is denied,
it is your responsibility to address this with your insurance company. I do not communicate with insurance companies on your
behalf. All subsequent therapy services such as phone calls over 10 minutes, etc., will be billed to you at $90 per hour in 15
minute increments. My role is limited to activities that are therapeutic in nature. I do not participate in legal proceedings. If you
should choose to issue a court-ordered subpoena for my participation in any court-related processes, I charge a retainer fee of
$1500, with an additional $120 hour fee for every hour I spend in legal depositions, case, preparation, travel, and/or witness time.
The fee is the responsibility of the subpoenaing party. If you should issued me a subpoena without my approval (see above), the
subpoena will be turned over immediately to my attorney and a bill will be rendered to you for immediate retainer fee payment. I
will only testify to the facts of the case and to my professional opinion.
Please initial indicating that you have read and understand the above section: _______
Records and Confidentiality: All of our communication becomes part of the clinical record. Records are property of Amber
Pilkington, LPC and Dignity Women’s Center. Adult records are disposed of seven (7) years after services end. Minor client files
are disposed of seven (7) years after the client’s 18th birthday. In the event of my incapacitation or death, my records will be
transferred to and become the property of Robin Boutwell, LPC-S. She may be reached at (210) 912-8464 or at Healing Hearts
Counseling in San Antonio, Tx.
Most of our communication is confidential, but the following limitations and exceptions do exist:
a) I am using your case records for purposes of peer supervision, training, or professional development. In such cases, to
preserve confidentiality, I will identify you by a pseudo-name and change other identifiable characteristics (i.e., sex, marriage
status, age),
b) I determine that you are a danger to yourself or someone else,
c) You disclose abuse, neglect, or exploitation of a child, elderly, or disabled person,
d) You disclose sexual contact within the context of a professional relationship with another mental health professional,
e) I am ordered by court to disclose information,
f) You direct me in writing to release your record,
g) I am otherwise required by law to disclose information.
If I see you in public, I will protect your confidentiality by acknowledging you only if you approach me first.
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In the case of marriage or family counseling, I will keep confidential (within limits cited above) anything you disclose to me without
your family’s or spouse/s/partner’s knowledge. However, I do encourage open communication between family members, and I
reserve the right to terminate our counseling relationship if I judge any confidential disclosure to be detrimental to the therapeutic
process.
Please initial indicating that you have read and understand the above section: _______
By your signature below, you indicate that you have read and understand this complete document, any questions that you have
about this statement have been answered to your satisfaction, that you were furnished a copy of this statement, and consent to
enter a counseling relationship Amber Pilkington, M.Psy., LPC, CART. By my signature, I verify the accuracy of this statement
and acknowledge my commitment to conform to its specifications.
______________________________________ _________________________________________________
Client’s Signature
Date
Amber Pilkington, M.Psy., LPC, CART
Date
Acknowledgement of Receipt of HIPPA Notice of Privacy Practices
(review and retain following pages)
I acknowledge that I have received and understood the HIPPA Notice of Privacy Practices for this office:
_________________________________________________________ ____________________________
Client signature (parent or guardian if minor patient)
Date
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Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how
you can get access to this information. Please review it carefully.
This notice effective August 1, 2010.
This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information. "Protected health information" is information about
you, including demographic information, that may identify you and that is related to your past, present, or future physical or
mental health or condition and related health care services.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your therapist, our office staff and others outside of our office
that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills,
to support the operation of the therapist's practice as necessary, and any other use required by law.
Treatment: We will use and disclose your protected health information as necessary to provide, coordinate, or manage your
health care and any related services. This includes the coordination of management of your health care with a third party. For
example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you,
or your
protected health information may be provided to a physician to whom you have referred to insure that the physician has the
necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. Such
information may be released to insurance companies, HMO’s and PPO’s managed care organizations, IPA’s, Medicare/Medicaid,
or other governmental or third party payors, or any organizations contracting with any of the above entities to perform such
functions.
Healthcare Operations: We may use or disclose, as needed, your protected health information to support the business activities
of your therapist's practice. These activities include, but are not limited to, quality assessment activities, employee review
activities, training of therapists associated with this practice, licensing, and conducting or arranging for other business activities.
For example, we may disclose your protected health information to graduate students who see clients at our office. In addition,
we may call you by name in the waiting room when the therapist is ready to see you. We may use or disclose your protected
health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected
health information in the following situations without your authorization: communicable diseases, abuse or neglect, food and drug
administration requirements, legal proceedings, law enforcement, coroners, and if you present a threat to yourself or to others.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization and opportunity to object
unless required by law. This office will not use or disclose any of your medical and financial information for any purpose not
stated above without your
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specific authorization. You, the patient, may revoke the authorization at any time. You may request restrictions on certain uses
and disclosures. This office is not required to agree to a requested restriction. You have the right to receive confidential
communications of your protected health information. You have the right to inspect, copy, and amend your protected health
information. You may also request an accounting of disclosures of your protected health information from this office. We are
legally obligated to maintain the privacy of your protected health information and to provide you with this Notice of Privacy
Practices and to abide by its terms. We reserve the right to change our privacy practices and apply revised privacy practices to
protected health information.
You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the
complaint and inform you of the findings. This office will make no retaliation against you because you registered a complaint. You
may also file a complaint with the Department of Health and Human Services.
PLEASE RETAIN THIS COPY FOR YOUR RECORDS.
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