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Adam Roderick Counseling Services
Adam Roderick, M.Ed., ALC, NCC
(205) 660-0602
Informed Consent
Credentials
I am a Nationally Certified Counselor (#330375) and Associate Licensed Counselor (#C2223A)
under the supervision of Tami Mayes Long, M.A., LPC-S, NCC, CEAP. I hold a Masters of
Education in Clinical Counseling from The University of Montevallo. I am a member of the
American Counseling Association and Alabama Counseling Association.
Confidentiality
It is my ethical obligation to uphold confidentiality. With very few exceptions, the information
discussed during our sessions and documentation is confidential. I will make every effort to keep
your personal information private. If you wish to have information released, you will be required
to sign a consent form requesting so. Limitations of confidentiality to which you need to be
aware:
 Mandated reporting of physical or sexual abuse
 Threats of suicide or homicide
 Cases where the clients signs a release of information
 Information necessary for supervision or consultation
 Court order or subpoena
I may consult with a supervisor or other professional counselor in order to give you the best
service. In the event that I consult with another counselor, no identifying information will be
released and anonymity will be upheld. If I receive a court order or subpoena, I may be required
to release some information. In such a case, I will consult with other professionals and limit the
release to only what is necessary by law.
Client Initials ___________
Confidentiality and Group Therapy
The nature of group counseling makes it difficult to maintain confidentiality. If you choose to
participate in group therapy, be aware that I cannot guarantee that other group members will
maintain your confidentiality. However, I will make every effort to maintain your confidentiality
by reminding group members frequently of the importance of keeping group communications
confidential. I also reserve the right to remove any group member from the group should I
discover that a group member has violated confidentiality.
Client Initials ___________
Rights and responsibilities
You have the right to ask questions about anything that happens in counseling. You have the right
to request that I refer you to someone else if you decide I'm not the right therapist for you.
You have a responsibility to inform me if you begin seeing another mental health professional or
counselor during the course of our time together. If you are seeing another mental health
professional, in an effort to ensure continuity of care, I will ask that we briefly discuss the nature
and goals of those interactions.
The process of counseling will be collaborative. We will, together, identify goals and means for
achieving those goals. Throughout the counseling process, we will take time to evaluate the work
we are doing and make adjustments accordingly. Your feedback and cooperation is a vital aspect
of a successful counseling relationship. It is important for you to be an active agent in your own
Adam Roderick Counseling Services
(205) 660-0602 - 4513 Valleydale Rd. Suite 2 Birmingham, AL 35242 - adamroderickcounseling@gmail.com
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care. Arrive on time, stay up-to-date with payments, and remain open and honest throughout our
time together.
Client Initials ___________
Appointments and fees
Appointments will be 45-50 minutes in duration. Sessions are $90.00 per clinical hour for
individual sessions and $120.00 per clinical hour for couple sessions. If we decide to meet for a
longer session, the fee will be prorated based on the hourly rate.
Accepted methods of payment include cash, check, or credit card. A $2.00 service charge will be
applied to all credit card payments. If you pay by check and the check fails to clear, you will be
charged an additional $25.00.
If you are late, we will end on time and will not extend our session. If you need to cancel or
reschedule a session, I ask that you provide me with 24-hours notice. If you miss a session
without canceling, or cancel with less than 24-hour notice, my policy is to collect the session fee
as charged to your on-file credit card. The client must agree to supply credit card information
during our initial meeting for this reason. This information will be kept in a secure file and will
not be used for anything other than cancellation fees.
Emergency phone calls of less than ten minutes are normally free. However, if we spend more
than 10 minutes in a week on the phone or if I spend more than 10 minutes reading and
responding to emails from you during a given week, I will bill you on a prorated basis for that
time. Any additional services (i.e. Letters to employer, educational institution, or Medical Doctor)
may result in fees. These fees will be discussed and agreed upon in session before services are
executed.
Currently, I do not accept any forms of insurance.
Client Initials ___________
Counseling process
Counseling is an individually tailored process which is designed to assist you in dealing with your
concerns, coming to a greater understanding of yourself, and formulating a plan to reach your
goals. Throughout the course of counseling, you may experience unpleasant feelings and
emotions. The experiences are a normal part of the counseling process and will be addressed as
they arise.
Counseling can bring about the possibility of and opportunity for positive changes. However, you
must determine the nature and amount of change you wish to make. Counseling can be a
challenging process that often calls for self-exploration, authenticity, and trust in the counseling
process. While the outcome of counseling is most often positive, the degree to which any
particular individual will reach their goals or achieve their desired level of satisfaction is not
predictable.
Client Initials ___________
Record Keeping
I will keep records of your counseling sessions and a treatment plan, which includes goals for
your counseling. These records are kept to ensure continuity in service. They will not be shared
except with respect to the limits to confidentiality discussed in the Confidentiality section. Should
the client wish to have their records released, they are required to sign a release of information
that specifies what information is to be released and to whom. Records will be kept for at least 7
years but may be kept for longer periods. Records will be kept either electronically through
Adam Roderick Counseling Services
(205) 660-0602 - 4513 Valleydale Rd. Suite 2 Birmingham, AL 35242 - adamroderickcounseling@gmail.com
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encrypted counseling software, on an encrypted USB flash drive, or in a paper file and stored in a
locked cabinet on site.
Client Initials ___________
Communication Policy
With the exception of true emergencies, contact outside of sessions should be limited to
scheduling concerns and financial questions. You may contact me through email or phone. In
order to protect confidentiality, I request email and telephone communications only to be used to
schedule or confirm appointments since they are not a secure or confidential method of
communication. It is your responsibility to understand the limits of confidentiality when
communicating through these means. If I am not available to take your call, or if it is after hours,
please leave a voicemail message. I will get back to you within 24 hours for urgent matters and
48 hours for non-urgent matters. If you have an emergency, please call 911, or the Crisis Center
at (205) 323-7777 or (800) 273-TALK.
I will not communicate with you through any forms of social media. This includes, but is not
limited to, responding to “Friend Requests” on Facebook, connecting through LinkedIn,
endorsing you through LinkedIn, or following you on Twitter. Any attempts to violate this
boundary will be discussed in session and may result in treatment termination.
Client Initials ___________
Counseling Relationship
The relationship between counselor and client is the container through which client change can
take place. As such, it is often one in which close emotional bonds develop. It is also a
professional relationship, in which appropriate boundaries must be maintained. For the most part,
the counseling relationship begins and ends at the counseling office. Although this is sometimes
difficult to understand, it is a necessary requirement for maintenance of the counseling
environment. As such, I cannot be expected to be involved in a social relationship or friendship of
any kind that exists outside of the counseling environment.
Client Initials ___________
Emergencies
Should an instance arise in which you feel there is an imminent threat to yourself or others, you
or a family member should call 911 and/or the Crisis Center Hotline at (205) 323-7777 or (800)
273-TALK.
Client Initials ___________
Adam Roderick Counseling Services
(205) 660-0602 - 4513 Valleydale Rd. Suite 2 Birmingham, AL 35242 - adamroderickcounseling@gmail.com
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Signature Page
I have read and discussed the above information with my counselor. I have been given the
opportunity to ask questions and discuss any concerns about these matters. I understand the risks
and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as
a client. I understand and agree to the cancellation policy. I understand that if I miss a scheduled
session and do not provide at least 24 hours notice or if the absence is not due to an emergency or
illness, I agree to pay the full payment for the session. I have read, understand and agree to the
information and policies described in the Informed Consent form. With your signature, you
indicate that you understand and agree to the above conditions. Further, you are also indicating
that you consent to counseling services provided by Adam Roderick, M.Ed., ALC, NCC.
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Adam Roderick Counseling Services
(205) 660-0602 - 4513 Valleydale Rd. Suite 2 Birmingham, AL 35242 - adamroderickcounseling@gmail.com