STATEMENT OF CONFIDENTIALITY

Please fill out the following form. You will receive a copy of your completed form via email.

If you need an offline copy of this form, please click here.

Informed Consent & Statement of Confidentiality

  • Welcome to Whole Hope Christian Counseling, LLC (EIN: 8 1 -4201353). In order that we start our relationship in a healthy way, I have put together this document to ensure that there are no misunderstandings about the various aspects of the counseling and wellness services.

    Background and Services We offer counseling, and consultation services to individuals, couples, and families in the areas of mental health, spiritual health, physical and nutritional well-being, and relationships. Angel Beeson’s credentials include a Master of Counseling Degree, Health Coach Certification, and Holy Yoga Instructor Certification. John Beeson’s credentials include a Master of Divinity. As Biblical Counselors, we are not individually licensed therapists by the State of Arizona. We offer counseling, mediation and conciliation services. The focus of our practice is adolescents and adults. We do not perform expert witness testimony in court. We do not prescribe or administer medication of any kind. We reserve the right to refer a client to another therapist or appropriate resource at any time if his or her needs in therapy are not a good match for our skills or experience. While Whole Hope Christian Counseling meets clients at New Life Bible Fellowship Church, Whole Hope Christian Counseling is not affiliated in any way with New Life Bible Fellowship Church.

    Financial Payment is expected before or at the time the service is rendered unless other arrangements have been made. For every week past due a charge of $10 will be incurred. By signing this document, you are agreeing to pay for the services rendered and any additional expenses that may be accrued. The fee for a counseling session is $80/hour. Reports required by physicians, employers, etc. will be assessed a $20.00 fee. A potential fee may be charged for telephone consultations in excess of 10 minutes. Checks returned by the bank will be charged an additional $15 fee. We reserve the right to change fees within 30 days’ notice. You have the right to be informed of all fees that you are required to pay and our refund and collection policies. Please discuss these with us if you have a concern.

    Insurance Whole Hope will not bill your insurance. We will be glad to provide you with an itemized receipt that you can submit to your insurance company in an attempt to receive reimbursement from them.

    Availability of Services This practice does not have the capability to respond immediately to counseling emergencies. True emergencies should be directed to the community emergency services (911) or to the local hotlines (Suicide hotline 1-800-784-2433, Arizona Teen Crisis (623) 879-9600 EMPACT suicide, crisis hotline Maricopa County 1-866-205-5229).

    Appointments Regular attendance at your scheduled appointments is one of the keys to a successful outcome in counseling. We reserve an hour or more for each appointment with a client. Appointments canceled at the last minute are detrimental to our practice. Therefore, we ask that you notify us a minimum of one full business day (24 hours, Monday through Friday) prior to your appointment if you need to cancel. You will be billed the full fee for appointments you fail to cancel in accordance with this policy. Please note that these are personal financial obligations that you are responsible for; not the obligations of your insurance company.

  • Appointment availability varies with the client load at the time. High demand appointments (evening hours and late afternoons) are likely to be sporadic in their availability. We reserve the right to limit our commitments of high demand appointment times to any particular client in order to meet the needs of all our clients.

    Privacy, Confidentiality, and Records Ordinarily, all communications and records created in the process of counseling are held in the strictest confidence. However, there are numerous exceptions to confidentiality defined in the state and federal statutes. The most common of these exceptions are when there is a real or potential life or death emergency, when the court issues a subpoena, or when child/elder abuse or neglect is involved. We also participate in a process where selected cases are discussed with other professional colleagues to facilitate our continued professional growth and to get you the benefit of a variety of professional experts. While no identifying information is released in this peer consultation process, the dynamics of the problems and the people are discussed along with the treatment approaches and methods.

    If you are under 18 years of age, please be aware that the law does provide your parents with the right to examine your treatment records. It is generally our policy to request an informal agreement from parents to forfeit access to your records directly, and agree to be provided with general information on how your treatment is proceeding, unless we feel that you are in danger.

    There are also numerous other circumstances when information may be released including when disclosure is required by the Arizona Board of Behavioral Health Examiners, when a lawsuit is filed against me, to comply with workers compensation laws, to comply with the USA Patriot Act and to comply with other federal, state or local laws. The rules and laws regarding confidentiality, privacy, and records are complex. The HIPAA NOTICE OF PRIVACY PRACTICES, details the considerations regarding confidentiality, privacy, and your records. This packet also contains information about your right to access your records and the details of the procedures to obtain them, should you choose to do so. Periodically, the HIPAA NOTICE OF PRIVACY PRACTICES may be revised. Any changes to these privacy practices will be posted in my office, but you will not receive an individual notification of the updates. It is imperative that you read and understand the limits of privacy and confidentiality before you start treatment.
  • Purpose, Limitations, and Risks of Treatment Counseling, like most endeavors in the helping professions, is not an exact science. While the ultimate purpose of counseling is to reduce your distress through a process of personal change, there are no guarantees that the treatment provided will be effective or useful. Moreover, the process of counseling usually involves working through tough personal issues that can result in some emotional or psychological pain for the client. Attempting to resolve issues that brought you to therapy in the first place may result in changes that were not originally intended. Counseling may result in decisions about changing behaviors, employment, substance use, schooling, housing, relationships, or virtually any other aspect of your life. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that counseling will yield positive or intended results. In the case of marriage and family counseling, interpersonal conflict can increase as we discuss family issues.

    Treatment Process and Rights Your counseling will begin with one or more sessions devoted to an initial assessment so that we can get a good understanding of the issues, your background, and any other factors that may be relevant. You have the right to refuse any recommended counseling plan or to withdraw consent to treat and to be advised of the consequences of such refusal or withdrawal.

    Our Relationship The client/counselor relationship is unique in that it is exclusively therapeutic. In other words, it is inappropriate for a client and a counselor to spend time together socially, to bestow gifts, or to attend family or religious functions. The purpose of these boundaries is to ensure that you and we are clear in our roles for your treatment and that your confidentiality is maintained. If there is ever a time when you believe that you have been treated unfairly or disrespectfully, please talk with your counselor about it. It is never our intention to cause this to happen to our clients, but sometimes misunderstandings can inadvertently result in hurt feelings. We want to address any issues that might get in the way of the therapy as soon as possible. This includes administrative or financial issues as well.

    Consent for Evaluation and Treatment Consent is hereby given for evaluation and treatment under the terms described in this consent document. It is agreed that either of us may discontinue the evaluation and treatment at any time and that you are free to accept or reject the treatment provided. In the case of a minor child, I hereby affirm that I am a custodial parent or legal guardian of the child and that I authorize services for the child under the terms of this agreement.
  • In the case of a minor child, please specify the following:

  • This field is for validation purposes and should be left unchanged.