The Gloaming at Santa Fe, LLC
Kathleen M. Fallon, Ph.D., NCC, LMHC (#0169931)
3 Caliente Road, Suite 6, Santa Fe, NM 87508
(505) 930-5001  drkittyfallon@thegloamingatsantafe.com
Counseling Informed Consent Agreement
Counseling is a relationship that works, in part, because of clearly defined rights and responsibilities
held by each person. This frame helps to create the safety to take risks and the support to become
empowered to change. As a counseling client, you have certain rights that are important for you to
know because this is your therapy, the goal of which is your wellbeing. Also, there are certain
limitations to those rights of which you should be aware. As your counselor, I have corresponding
responsibilities to you.
My Responsibilities to You as Counselor
1. Respectful, Competent, and Ethical Professional Service
a. You have every right to be treated with the utmost dignity, compassion, and respect in my
work with you. You have every right to be accepted and not discriminated for any reason.
b. I will provide you counseling service within the bounds of my competence. In my best
professional judgment, if I believe a counselor with different competence specialties
would better serve you, I will provide a referral. The following is a brief description of my
training and approach to counseling
i. I earned a Masters of Education (M.Ed.) and Specialist in Education (Ed.S.) with a
Marriage and Family Counseling major, and Doctor of Philosophy (Ph.D.) with a
Mental Health Counseling major from the Counselor Education Department at the
University of Florida. My counseling training and experience were in crisis
counseling, outpatient substance abuse treatment, inpatient crisis stabilization
emergency screening, university career services, and private practice. In addition,
I worked for 10 years as a counselor educator preparing graduate students to work
as professional counselors.
ii. My approach to counseling integrates multiple theoretical frameworks, including
but not limited to Feminist, Cognitive Behavioral, Humanistic, Existential,
Narrative, and Internal Family Systems. I infuse compassion, dignity, humor,
intuition, and supportive challenge within my work. My foundational assumptions
about all people include but are not limited to the following:
1. People are capable of change;
2. People have the capacity to identify and manifest their own answers;
3. People’s thoughts, feelings, behaviors, relationships, and current &
historical cultural contexts influence them in developing and maintaining
obstacles and generating solutions;
4. People invest energy in multiple life areas, roles and contexts - all of which
they are welcome to work on in counseling - including but not limited to:
life work/career; family, friends, community; finances; romance/intimacy;
health & self care; social & fun; personal & spiritual development; and
physical environment;
5. I approach people from a wellness-based, holistic perspective; and
6. The counseling relationship is key to cultivating healing within counseling.
iii. In the State of New Mexico, I am a Licensed Mental Health Counselor (LHMC). A
“LMHC is intended as a transition between the required degree and the completion
of supervised training required for licensure as a professional mental health
counselor...All work must be under appropriate clinical supervision (New Mexico
Administrative Code, Title 16 Occupational and Professional Licensing, Chapter 27
Adapted from Brown, L.S. (2010). Psychotherapy information disclosure statement.
Page 1 of 4; Updated August 2015
Counselors and Therapists Practitioners, Section 9.9). My Clinical Supervisor is Rev.
Dr. Bernardo Monserrat, and his phone is (505) 490-1129.
c. As a professional member of the American Counseling Association, a National Certified
Counselor (NCC) with the National Board for Certified Counselors (NBCC), and a Licensed
Mental Health Counselor (LMHC), I adhere to the following state and national ethics and
professional standards:
i. 2014 ACA Code of Ethics (http://www.counseling.org/knowledge-center/ethics)
ii. NBCC Ethics Policies and Procedures (http://www.nbcc.org/Certification/Ethics)
iii. New Mexico Counseling and Therapy Practice: Rules and Laws
(http://www.rld.state.nm.us/boards/Counseling_and_Therapy_Practice_Rules_and
_Laws.aspx)
2. Confidentiality
a. Barring specific legal exceptions described in the following item, you have the absolute
right to confidentiality in your counseling. I cannot and will not tell anyone else what you
have told me, or even that you are in counseling with me without your prior written
permission. Under the provisions of the Uniform Health Care Information Act of 1985, I
may legally speak to another health care provider or a member of your family about you
without your prior consent, but I will not do so unless the situation is consistent with the
following legal exceptions (see 1.e.). I will act always so as to protect your privacy even if
you do release in writing to share information about you. You may direct me to share
information with whomever you choose, and you can change your mind and revoke that
permission at any time. You may request anyone you wish to attend a counseling session
with you.
b. Should we meet in public, I will not acknowledge our counseling relationship. You and I
will negotiate your preferences for public meetings to protect your confidentiality and
privacy.
c. You are also protected under the provisions of the Federal Health Insurance Portability
and Accountability Act (HIPAA). This law insures the confidentiality of all electronic
transmission of information about you. To insure confidentiality to the highest degree
possible, I use the encypted Hushmail application to communicate via email. If you elect
to communicate with me by email, please be aware that email is not completely
confidential. All emails are retained in the logs of my internet service provider. While
under normal circumstances no one looks at these logs, they are, in theory, available to
be read by the system administrator(s) of the internet service provider. Any email I
receive from you, and any responses sent to you, will be maintained in your counseling
record.
d. For clients engaging in couples counseling, if you and your partner decide to have some
individual sessions as part of the couples counseling, what you say in those individual
sessions will be considered to be a part of the couples therapy and can and probably will
be discussed in your joint sessions. Do not tell your counselor anything you wish kept
secret from your partner.
e. The following are legal exceptions to your right to confidentiality. I will inform you of any
time when I think I will have to put these into effect.
i. If I have good reason to believe you will harm another person, I must attempt to
inform that person and warn them of your intentions. I must also contact the
police and ask them to protect your intended victim.
ii. If I have good reason to believe you are abusing or neglecting a child or vulnerable
adult or if you give me information about someone else who is doing this, I must
inform the State of New Mexico Children Youth and Families Department or Adult
Protective Services Division.
iii. If I have good reason to believe you are in imminent danger of harming yourself, I
may legally break confidentiality and call the police and/or the Crisis Hotline. I am
obligated to do this and would explore all other options with you before taking this
Adapted from Brown, L.S. (2010). Psychotherapy information disclosure statement.
Page 2 of 4; Updated August 2015
step. If at that point you are unwilling to take steps to guarantee your safety, I
would call the police and/or the Crisis Hotline.
3. Record-Keeping
a. I keep very brief records, noting intake information, the session date, what interventions
happened in session, and the topics discussed.
b. Under the provisions of the Health Care Information Act of 1985, you have the right to a
hard copy of your file at any time.
c. You have the right to request I correct any errors in your file.
d. You have the right to request I make a copy of your file available to any other health care
provider at your written request.
e. Your records are maintained in a secure electronic location that is password protected.
4. Other Rights
a. You have the right to ask questions about anything that happens in counseling. I am
willing to discuss how and why I have decided to do what I am doing and to look at
alternatives that might work better.
b. You can ask me to try something that you think will be helpful.
c. You can ask me about my training for working with your concerns and can request I refer
you to someone else if you decide I am not the right counselor for you.
d. You are free to leave therapy at any time.
Your Responsibilities as a Counseling Client
1. Attendance and Canceling/Rescheduling
a. I reserve our scheduled appointment time for you and make no other commitments for
that time. I expect you to arrive on time for your appointment. If you arrive late, we will
end session on time and not extend over into someone else’s time. If you need to cancel
and reschedule your appointment, I ask you provide 24-hours notice so I may offer that
time to someone else. Please call and leave a message on my office phone 505-930-5001,
which has a date and time stamp. With the exception of an emergency, if you fail to show
for your session and fail to provide 24-hours notice, you will be charged for the session.
Payment for the missed session will be due at your next appointment. If you have a
pattern of more than 2 cancelled or 2 no show sessions, we will address whether this is
the best time for us to be working together. If you have cancelled or not shown for a
scheduled session and have not contacted me to reschedule, I will assume you have
chosen to discontinue working together and will close your file.
2. Session payment
a. I value providing services that honor and respect your needs and mine. Intentionally I
developed a fee structure that balances my skills, experience, and responsibilities with
your resources. I designed a diverse array of individual and group services, packages,
classes and workshops to be accessible to as many people as possible. This diverse array of
services and prices constitute my “sliding scale.” I work on a fee-for-service basis and at
this time do not accept insurance. Services are non-refundable.
b. If paying on a per-session basis, I require payment at each session. Payment for packages
are due in full no later than the first session, unless specified otherwise in
writing. Payment for workshops, classes, or time-limited groups are due in full no later
than the workshop, first class or group. I accept cash, check, or credit card. I generate
invoices and accept credit card payments using Square. Checks are made payable to The
Gloaming at Santa Fe, LLC.
c. Counseling Fees and Packages (Updated August 2015)
i. Custom Counseling Packages
1. 1-hour Initial Consultation - No Charge
2. Hourly Individual Counseling Rate - $100
3. 30-minute Individual Counseling Rate - $50
ii. Classes, Workshops, and Groups
Adapted from Brown, L.S. (2010). Psychotherapy information disclosure statement.
Page 3 of 4; Updated August 2015
1.
2.
3.
4.
5.
2-hour class - $40 per class session
3-hour workshop - $40
6-hour workshop - $80
90-minute Group Counseling Rate - $30 per group
For a list of all classes, workshops, and groups and to register, please visit
my Events page on my coaching website.
iii. Counseling Packages
1. Aspen
a. 4, 1-hour Individual Counseling Sessions Monthly
b. $400 per month
2. Lavender
a. 2, 1-hour Individual Counseling Sessions Monthly
b. 2, 30-minute Individual Counseling Sessions Monthly
c. $300 per month
3. Jasmine
a. 4, 30-minute Individual Counseling Sessions Monthly
b. $200 per month
iv. At this time, I do not accept third-party insurance or other managed care options.
Complaints
If you are unhappy with what is happening in counseling, I hope you will talk about it with me so I
can respond to your concerns. I will take such critique seriously and with care and respect. If you
believe I have been unwilling to listen and respond or that I behaved unprofessionally and/or
unethically, you can report the behavior to my Clinical Supervisor, Rev. Dr. Bernardo Monserrat at
(505) 490-1129 and/or the State of New Mexico Regulations and Licensing Department, Counseling
and Therapy Practice Board, 505-476-4622. Also, you are free to discuss your complaints about me
with whomever you wish, and do not have any responsibility to maintain confidentiality about what I
do that you do not like, since you are the person who has the right to decide what you want kept
confidential.
Client Consent to Psychotherapy
I have read this agreement, had sufficient time to be sure that I considered it carefully, asked any
questions I needed, and understand it. I understand the limits to confidentiality required by law. I
agree to pay the per session counseling fee and/or package I selected. I understand my rights and
responsibilities as a client, and my counselor’s responsibilities to me. I agree to enter a counseling
relationship with Kathleen M. Fallon, Ph.D., NCC, LMHC. I know I can end counseling at any time I
wish and that I can refuse any requests or suggestions made by my counselor. I am over the age of
eighteen. If under eighteen, a parent(s) or guardians provide informed consent.
Client Signature:
Date:
Client Signature:
Date:
Date:
Kathleen M. Fallon, Ph.D., NCC, LMHC
Adapted from Brown, L.S. (2010). Psychotherapy information disclosure statement.
Page 4 of 4; Updated August 2015