Info for which I need a real live signature

Referral: ____________________________________________________Relationship to Referral: ________________________________________________________________

May I notify the referral that you have come for an appointment?  _____Yes  _____No


Pastor________________________________________________ _____Congregation__________________________________________________________________________
May I notify the pastor that you have come for an appointment?  _____Yes  _____No

Consultation: You have my permission to consult with the following persons who may be of help:


Name__________________________________________________________Relationship:_______________________________________________________________________
Name__________________________________________________________Relationship:_______________________________________________________________________
Name__________________________________________________________Relationship:_______________________________________________________________________
Name__________________________________________________________Relationship:_______________________________________________________________________
Name__________________________________________________________Relationship:_______________________________________________________________________











Confidentiality

Counseling depends on you trusting that whatever is said in my office will never be shared with any other persons apart from your written permission. There are some limits to confidentiality under the law. These are:


  • If I believe you are likely to harm yourself and/or another person, I may take action necessary to protect you or others others by contacting law enforcement officers or a physician.
  • If I have cause to believe that a child has been or may be abused or neglected, I am required to make a report to the appropriate state agency.
  • If I have cause to believe that an elderly or disabled person has been or may be abused, neglected, or subject to financial exploitation, I am required to make a report to the appropriate state agency.
  • If you disclose information about a person from whom you've sought counseling in the state of Texas behaving toward you in a sexually inappropriate manner, I must report this to the board (your identity may remain anonymous at your request).
  • If your records are requested by a valid subpoena or court order, I must respond (Note I keep very simple notes in the medical record. The law also allows me to keep a separate set of personal notes which are not subject to subpoena.)
  • If you are a minor (under the age of 18), then parents and/or legal guardians have a legal right to know the content of counseling. However, I am committed to maintaining confidentiality in my work with children and teenagers in the same way I do with adults. I will break confidentiality if I believe there is risk of harm to the client or to someone else. Beyond this, I will encourage to a minor client to share information with parents/guardians if I believe it is critical.


Acknowledgment of Email and Text as a Non-Secure Form of Contact

The law says that all communication online must be through secure, encrypted email servers. This option is available through my online system. However, this can also be very cumbersome. If you are okay with us using regular email and texting to communicate, you will need to give me permission to do so. Initial:___________

I understand regular email and texts messages are not secure forms of communication. I give permission to Dr. Eades to contact me via email and text, recognizing if a matter is of particular sensitivity I can communicate by phone or mail. Initial:__________

Commitment To Treatment Statement

  • I agree to make a commitment to  the treatment process. I understand that this means I have agreed to be actively involved in all aspects of treatment including:
  • Attending sessions (or giving Wes at least 24 hours notice when I can't be present).
  • Voicing my opinions, thoughts, and feeling honestly and openly, whether negative or positive.
  • Being actively involved during sessions.
  • Taking medications, if prescribed by a medical doctor, as they are prescribed (and discussing any ideas for changing meds with the doctor).
  • I also understand that, to a large degree, my progress depends on the amount of energy and effort I make. If it is not working, I will discuss it with Wes. In short, I make a commitment to living a full and meaningful life.


I have read the policies and procedures and I am willing to work with Wes accordingly, I have carefully considered the commitment to treatment statement and I am willing to make this commitment as the statement stands or based on amendments that Wes and I have mutually agreed upon.

Signature____________________________________________________________________________

Name____________________________________________________________________________ Date_____________________________________







Texas State Licensing Boards: 888-963-7111