Whitney Nevins, M.A. MFT
4015 South Cobb Drive, Ste 10
Smyrna, GA 30080
404-907-3592
Treatment Contract/Informed Consent and Administrative Policies
Welcome. The following information is meant to inform you about my policies and my
understanding of our professional relationship. Therapy is a relationship that requires open
communication. If you have any questions about these or any other aspects of your
psychotherapy, please feel free to bring them up at any time.
Professional Background and Philosophy:
I obtained a Master's of Arts Degree in Marriage and Family Therapy from Richmont
Graduate University. I also obtained a certificate of specialization in both trauma counseling and
addictions counseling from Richmont Graduate University. I am not yet independently licensed
and am currently working towards Associate Licensure as both a Licensed Associate Marriage
and Family Therapist and a Licensed Associate Professional Counselor in the state of Georgia.
Thus, I am currently being supervised by and am under the direction of Alyza Berman, LCSW.
 I provide psychotherapy for individuals, couples, and families. I work with adolescents,
young adults, & adults.
 My areas of specialization based on interest, education, training, and clinical experience
include but are not limited to, eating disorders, anxiety disorders, addiction, mood
disorders, women's issues, and family dynamics-related concerns.
 I have been trained to incorporate spirituality and/or faith into the counseling relationship
and goals, but will only do so with the consent and expressed interest of individual clients
and/or families. I practice from an eclectic theoretical orientation, which combines
components and techniques of Family Systems, Psychodynamic, Cognitive Behavioral,
and Structural theories and therapies.
 I believe in the resilience of the human spirit and that individuals, couples, and families
have many strengths with which to work and build upon. I practice from a strengthsbased perspective in many ways, but strive to help clients identify stressors and elicit
healthy growth and change.
The Counseling Relationship and Length of Therapy:
 Each person, couple, or family who seeks counseling comes with unique experiences and
concerns. The relationship of the counselor to the client(s) will be characterized by
professional dignity, expertise, warmth, and acceptance. Therapy is a learning process
that strives for insight and growth, allowing the persons involved to better understand
themselves and others. Client autonomy is highly valued. A collaborative therapeutic
rapport/relationship is also highly valued.
 It is impossible to guarantee specific results regarding therapy. However, I will work
together to achieve the best possible results for you. It is essential that you are actively
involved in setting your goals.
Fees and Length of Therapy:
 My regular fee is $80 per fifty-minute therapy hour and $100 per initial assessment. My
fees are the same for individuals, couples and families. I do not charge for brief phone
calls, but do charge for longer calls (15 minutes or more.) Fees for these calls are due at
the next appointment and are as follows: 15 minutes = $30.00, 20 minutes = $40.00, 30
minutes = $60.00.
 If you are late for your appointment, that amount of time is deducted from our session.
Since I am not a fully licensed clinician, at this time, I am not associated with any
insurance panels and cannot accept payment directly. All sessions must be self-pay and
payments will be made out to and/or processed by my current supervisor/director Alyza
Berman, LCSW. Payment is due in full at the time of service, unless prior arrangements
have been made. Payment can be made with cash or check. If you choose to pay by
check, please note that there is a $25 charge for any returned checks.
 Fee Increase: You will be given 3 months advance notice if I increase my fees.
Cancellations:
 If you cannot keep your appointment time, please give me at least 24 hours notice so that
I can make the time available for others. If you cancel with less than 24 hours notice or
you miss a scheduled appointment, you will be charged for that appointment.
 If you are going to be more than 15 minutes late for your appointment, please let me know
by calling 404-907-3592. Please leave a message if you do not reach me directly.
Otherwise, if you are more than 15 minutes late, I may assume you are not coming and
may be unavailable. If this happens, you will still be charged for the missed appointment.
Fees are not prorated if you are late.
Confidentiality & Exceptions:
Confidentiality is an essential part of the therapeutic process and is a commitment that I make to
you. Consistent also with the mental health laws of Georgia, I will not release any information
about you without your written consent. There are specific exceptions to this commitment of
confidentiality:
• When I consult with other mental health professionals about our therapy. Specific
identifying information is not necessary in that instance.
• When I feel as though you are a threat to your own or someone else’s safety.
• When a minor child is endangered by abuse or neglect.
In each of these instances, I will make every effort to speak with you before I speak with anyone
else. If you are seeing another healthcare provider, it may at times be necessary to exchange
information regarding your treatment. In those cases, you will be asked to complete an
authorization to release information.
 Please review the Notice of Privacy Practices provided to you as part of this new client
information. It describes in more detail your rights with regard to Protected Health
Information. By signing this Administrative Policies sheet, you are acknowledging your
receipt of the Notice of Privacy Practices.
 Also, Mental health professionals may disclose confidential information without the
consent of the client in order to (a) provide professional services, such as psychotherapy
and psychological testing; (b) operate a professional practice, such as handling phone
calls and scheduling appointments through office staff; (c) obtain peer consultations with
other professionals, although peer consultations do not require disclosure of the identity
of a client; (d) obtain payment for services, including mailing statements of accounts; (e)
comply with mandated reporting requirements in situations in which abuse or neglect of
a child, elderly person, or disabled or vulnerable individual is reasonably suspected; (f)
protect the client, therapist or others from harm, including situations in which an
immediate threat of physical violence against a readily identifiable victim is disclosed to
the practitioner; (g) comply with legal requirements in the context of civil commitment
proceedings, including situations in which an imminent threat of self-inflicted damage is
disclosed to the practitioner; (h) comply with legal requirements such as court orders,
including situations in which the client is examined pursuant to a court order; and (i)
provide a defense in situations in which such information is necessary for the
practitioner to defend against a disciplinary board complaint or malpractice action
brought by the client. It is possible that confidential and privileged information may be
released without client consent or authorization in the aforementioned circumstances,
although in such cases the disclosure of confidential information is limited to the
minimum that is necessary to achieve the purpose. Your signature below indicates you
agree to hold me, Whitney Nevins, M.A. MFT, and/or my supervisor/director, Alyza
Berman, L.C.S.W, harmless for releasing information under any of the above conditions.
 During couple, family, or group therapy I will not disclose information outside the
treatment context without a written authorization from each individual competent to
execute a waiver. During marital therapy, although the marriage itself is the “client” it is
not unusual for couples to meet with me individually. I will use my own professional
judgment concerning the degree to which I disclose “secrets” within a marriage or
family, and will work with the secret holder to share information relevant to achieve
therapeutic goals. Client files are kept in a locked file cabinet at our office. I will
confidentially store, safeguard, and dispose of client records in
accordance with applicable laws and professional standards. Files are maintained for 10
years in accordance with ethical and legal guidelines. All personally identifiable
information is destroyed at the time of file disposal.
Communication and Emergency Contact:
 I do my best to return phone calls within 24 hours; however, occasionally there are
unavoidable delays. If you need to speak with me immediately, please indicate so on my
voicemail, 404-907-3592 and I will make every effort to call you back as soon as I
possibly can.
 I offer outpatient psychotherapy services and do not provide 24-hour emergency care. If
you are experiencing a life-threatening emergency, call 911. If you are experiencing a
clinical emergency that requires urgent attention, please call or go to Ridgeview
Institute's Access Center: 770-434-4567, 995 South Cobb Drive Smyrna, Georgia 30080.
Communication Via Text Messaging, Email, and other Technologies:
 While I do receive texts and emails, all cancellations must be confirmed by me. Therefore,
if you cancel an appointment via text and/or email, it will not be considered canceled
unless confirmed by me through a response. In addition, I will not engage in a text
message or email conversation that I feel is important to discuss in person.
Client Responsibilities:
 You, the client, are an integral part of the counseling process. It is expected that you will
prioritize therapy and work towards personal growth. Success is highly dependent upon
the amount of time and energy you devote to this experience. Should questions or
concerns arise during therapy, please share them with me so we may make the necessary
adjustments. Suspension, termination, or referral may be initiated by either the counselor
or the client. These decisions shall be discussed in detail to explore the nature of the
therapeutic relationship, the best way to meet your needs, and your level of commitment
to the counseling process.
 A client seeking my services in conjunction with another ongoing professional mental
health relationship must first gain permission from his or her original therapist. Clients
who wish to terminate therapy agree to first meet with me before making a final decision,
as termination can be constructive process that deserves appropriate attention.
 Due to an inherent conflict of interest on the part of a therapist working with a couple or an
individual coming for help in resolving relationship problems, your signature below
indicates an agreement to refrain from subpoenaing Whitney Nevins, M.A. MFT and/or
Alyza Berman, LCSW for testimony or records in the event that court proceedings
concerning such issues as divorce, custody disputes, or other matters develop at a later
date.
Interruptions in Therapy:
 Occasionally there will be interruptions in therapy due to vacation, illness, or personal
reasons. I will notify you as far in advance as possible for planned interruptions. In the
event of an unplanned interruption, you will be notified to provide information regarding
rescheduling your appointment or, if the interruption will be extended, information for
another contact with whom you may meet in case of emergency or for purposes of
continued care.
Physical Health:
 Physical health is very important to your emotional well-being. I encourage my clients to
have a complete physical examination if they have not done so in the past year. Please
note that I am not a medical doctor and cannot prescribe medication.
Benefits and Risks of Counseling:
 The potential benefits of entering counseling may include obtaining a professional opinion,
an increased understanding of yourself and others, and personal and interpersonal growth.
Potential risks may include possible disagreement with the opinions offered, emergence
of hidden traumatic memories, increased relational strain, or the discovery of unpleasant
feelings. Please note that such experiences may be a normal part of the therapy process.
Counseling may also result in the client making significant life decisions such as
reconciliations, separations, or lifestyle changes.
 Although I cannot foresee all potential risks of our therapeutic relationship, I will attempt
to inform you of expected potential risks specific to our work together. It is important to
note that I cannot guarantee a positive outcome. Alternative treatment options include
services provided by another counselor or a psychiatrist/psychologist.
Code of Conduct:
 I adhere to the Code of Conduct for Licensed Marriage and Family Therapists, which has
been adopted by the Georgia Licensing Board and AAMFT. A copy of this Code is
available on request: American Association for Marriage and Family Therapy, 112 South
Alfred Street, Alexandria, VA 22314; Phone: (703) 838-9808; Fax: (703) 838-9805;
Website: www.aamft.org.
Client Signature:
Your signature indicates that you have reviewed and understand this document, have had all
questions answered to your satisfaction, and agree to adhere to the policies. A copy for your
records has also been received.
____________________________
Client Signature (or signature of parent if client is under age 18)
___________________
Date: