Informed Consent for Treatment
OUTPATIENT SERVICES CONTRACT
This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that you can discuss them with Queen Ravenden at your next meeting. When you sign this document, it will represent an agreement between you and Jacquelyn “Queen” Ravenden Feliciano.
Sessions are scheduled as needed at least 24 hours in advance. If you need to reschedule or cancel, you must provide 24 hours advance notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. If you need to miss an appointment, every attempt should be made to reschedule your appointment within the same week. A failure to do so will result in no refund for the appointment. If regular attendance becomes a challenge and you miss more than 3 consecutive visits in a year, we may not be able to continue to provide services.
Your healer is often not immediately available by telephone. The telephone is answered by a voicemail that is monitored periodically throughout the day. We will make every effort to return your call the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please indicate times when you will be available on the voicemail message. Telephone calls are offered as a professional courtesy and this service does not constitute an emergency service. We are not responsible for your behaviors or decisions occurring outside the consultation room at any given time, whether before or after a telephone call or consultation. If you are unable to reach us and feel that you can’t wait for us to return your call, contact 911, your family physician or the nearest emergency room.
Contents of all sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:
We prefer to use email only to arrange or modify appointments. Please do not use email to send content related to your healing sessions, as email is not completely secure or confidential. If you choose to communicate with us by email, please be aware that all emails are retained in the logs of your and our internet service providers. You should also know that any email we receive from you, and any responses that we send to you, will be a part of your treatment record.
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, mental health professionals are required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, mental health professionals are required to notify legal authorities and make reasonable attempts to notify the family of the client. If a client states or suggests that he or she is abusing, has abused or will abuse a child (or vulnerable adult), mental health professionals are required to report this information to ACS, APS and/or the police. Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.
Your healer participates in regular supervisory consultation. During a consultation, we make every effort to avoid revealing the identity of our clients. The supervisor is also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together.
Your participation in all sessions is voluntary and you have the right to withdraw from treatment without adversity at any time. It is recommended that when termination is considered, you discuss this with your healer, so that you can create a plan for termination to minimize any possible negative effects. If you don’t show up for 3 consecutive scheduled appointments, your treatment will be considered canceled and terminated. An email will be sent to you acknowledging the termination.
Your appointment booking indicates that you have read the information in this document, were provided accurate information, and agree to abide by the terms outlined above during our professional relationship.