GraceWorks Counseling

Adult Counseling Request

 
Adults age 18 and over

Spouse

For Blended Families

Medications

Other Information

In order for us to best help you, please tell us the nature of your visit to our office.
* Required

Minor Counseling Request

 
Minors age 17 and under

Mother

Father

Additional Information

GraceWorks
COUNSELING PROCEDURES AND AGREEMENT
I. Appointment Policies

APPOINTMENTS: Counseling services are provided by appointment only. Appointments can be made by calling the GraceWorks office during regular business hours (Monday through Thursday, 8:30 a.m. – 5:00 p.m., and Friday 8:30 a.m. – Noon) at 903-533-1817. Counseling sessions are generally 50 minutes in length and are made according to the schedules of the counselor and client. Adults (persons over the age of 18) seeking appointments are required to make their own appointments due to confidentiality concerns (see below).

 

FEES: Clients who are members of Green Acres Baptist Church will be charged a fee of thirty (30) dollars per session. Non-members will be charged a fee of sixty (60) dollars per session. All fees are due prior to the start of each session unless other payment arrangements have been approved in advance. GraceWorks does not accept insurance reimbursement. Should you require a receipt to file for reimbursement yourself, one will be provided for you at no charge.

 

COURT APPEARANCES: We reserve the right to suggest community referrals in cases where it becomes apparent that court testimony by a counselor will be required. These cases may include (but are not limited to): child custody, divorce proceedings, criminal cases, et al. If any GraceWorks counselors are subpoenaed to appear and/or testify in a court case, the fee will be one hundred fifty dollars ($150.00) per hour for time out of the office. Additionally, client will be charged mileage, at the rate allowed by the Internal Revenue Service, if travel is required outside of the city limits of Tyler, TX.

 

CANCELLATION POLICY: 24-hour cancellation of an appointment is required. We understand that emergencies do arise, therefore ONE (1) late cancellation will be allowed. Thereafter, if an appointment is not cancelled 24 hrs. prior to the appointment time, the client will be charged for that session and will not be rescheduled until payment is made for that appointment. There are a limited number of appointments available each week, and your consideration in this area may clear the way for someone else to use the time that had been reserved for you.

 

NO-SHOW POLICY: As above, when you do not keep your appointment, you may be preventing someone else from receiving needed counseling services. Failing to appear for your appointment will result in the cancellation of all future appointments until payment is made for the missed session.

 

EMERGENCIES: In the event of what you may consider to be a counseling emergency, you are asked to call the GraceWorks offices during regular business hours to speak with your counselor or an available professional. Calls to counselors will be returned as each professional’s schedule permits. After-hours, please call 9-1-1 if the situation is life-threatening, or call the office number at 903-533-1817 and follow emergency call-back instructions. GraceWorks maintains an active on-call strategy, and the therapist who is on-call will return your call as promptly as possible.

 

MINOR CONSENT TO CARE: Proof of custody or guardianship will be required to initiate counseling services for a minor child (under age 18). This proof may take the form of a finalized divorce decree, legal guardianship paperwork, or other validation of an adult’s right to consent to mental health treatment for a minor child. We will make a photocopy of this information for the minor’s client file. If this information is not available, services will not be provided.

II. Explanation of Confidentiality

CONFIDENTIALITY: All communications that occur between counselor and client are held in the strictest confidence. No information will be released without written release/authorization by the client or legal guardian. However, under certain circumstances according to Texas statutes, confidentiality may be revoked:

 

§ if the client is judged to be a danger to self or others
§ if child or elder abuse is suspected/reported
§ if requested by parents of minor clients
§ if subpoenaed or court ordered from a judge

 

In these cases, the proper medical, social, or law enforcement agencies will be notified as well as appropriate family members or significant others and verification of such notification will be made in the client’s file. Your counselor may also staff your case with other professionals in order to provide you with the best services possible; this is done without using your name or other particular identifying information. All client records are maintained in locked cabinets with no access by persons other than GraceWorks staff members. Clients with questions concerning policies, appointment times, or other matters are required to call for that information personally. NO information will be given to family members, spouses, etc., in order to protect the interests of each client without a signed release of information form, which is available from the GraceWorks office or individual counselor.

 

ELECTRONIC COMMUNICATIONS: E-mails, fax transmissions, or other electronic communications sent to GraceWorks staff members will be treated with the highest confidentiality standards; however, it is important to know it cannot be guaranteed that these communications will only be seen by the person to whom they are directed. If the information you wish to transmit is of a sensitive or confidential nature, it is advised that it be dropped off personally at the GraceWorks office to ensure an unbroken chain of communication.

 

TELEPHONE COMMUNICATIONS: Each client is asked for a preferred telephone number for confirmation of appointments and other office needs. Please make certain that this number is private and that information may be left on voice mail for you should contact be needed. In the event that a counselor returns a client’s phone call requesting information and/or assistance, please know that these calls will be documented in the client’s file. GraceWorks counselors reserve the right to limit services provided by telephone, e-mail, or other form of communication other than face-to-face sessions.

 

COMMUNICATIONS WITH OUTSIDE SOURCES / PROVIDERS: GraceWorks personnel may consent to communicate with persons as directed by individual clients at their request provided a signed release for that specific communication is in the client’s file. These release forms will be provided at the client’s request by office personnel or the counselor of record, and must be signed in the presence of an individual who can verify that the signature is that of the client. A counselor may also request the privilege of communicating with an outside provider or source, and permission may be given by the client to do so through their signature on a release form.

II. Explanation of Counseling

CREDENTIALS: Each counselor at GraceWorks has been found to be professionally competent to offer services through a number of credentialing sources. You may ask your counselor for these sources, or may request to see them from our office staff. Each counselor is responsible for maintaining their credentials and staying in satisfactory compliance with the ethics and rules of each credentialing organization.

 

GOALS OF COUNSELING: In your initial session(s), your counselor will discuss the purpose and goals of counseling with you. You will also be informed of possible therapeutic techniques that may be utilized during your time in counseling. The counselor will inform you if any other professional will be consulted or utilized to provide services to you and will also inform you if he/she is under supervision of any other licensed mental health provider. If so, you will be given the name and qualifications of said supervisor.

 

HISTORY: In the initial phases of counseling, your counselor may deem it necessary to take a complete background history including, but not limited to: family of origin, personal development, medical, spiritual, marital, sexual, and legal information. This information may be requested in order to determine the appropriate counseling modalities and to ensure the best possible care. Your permission to grant this inquiry is given by your signature on this agreement.

 

COUNSELING THEORIES / TECHNIQUES: A varied array of counseling and therapy techniques may be employed or suggested during your course of treatment. You have the right to ask for explanations of suggested treatments or to refuse to comply with any suggestions made by your counselor, at which time therapy services may be terminated with appropriate referrals given by the counselor or counseling center.

 

RISKS OF COUNSELING PARTICIPATION: Please be advised that there are no guarantees of positive outcomes associated with the delivery of counseling or therapy services. Every effort will be made to ensure that each client has the best and least stressful experience while utilizing intervention services at GraceWorks. It is important to consider that talk therapy and other forms of intervention may, in some cases, actually heighten stress for some individuals or carry other risks for participation. Should you feel this is the situation in your case, please discuss this with your counselor. Each client has the right to request referral or terminate services at any time during treatment.

 

ALTERNATIVES TO COUNSELING: It is important to consider that there are other avenues of possible improvement for certain conditions/situations other than engaging in the formal counseling process with a professional. These include, but are not limited to: speaking with a member of the clergy; speaking with your physician; talking with a good and trusted friend; attending an issue-specific support group; accessing issue information over the Internet or through telephone help line services; the use of self-help media, such as books, CDs, DVDs, and videos; attending seminars, conferences and retreats that deal with topics of interest; and others. These are presented to provide you with full information concerning many of the possible choices of intervention you as a client may choose to pursue in place of or in addition to professional counseling services.

II. Other

CHILDREN: Children under 13 years of age must be accompanied by an adult to the office and supervised while in the waiting area. All children must remain in the waiting room during their visit to our offices except during their appointment with their counselor. We reserve the right to ask adult clients to reschedule appointment times if underage children are brought to appointment times with the purpose of leaving them unattended in the waiting areas.

 

REFERRALS: Therapists and ministry leaders reserve the right to suggest to a client that he/she seek services outside the ministry offerings: if issues presented would require long-term counseling and therapy interventions, if the need is outside the scope of professional expertise or personal competency; or there is a break in the protocol or trust between a counselor and client. At that time, at least three community referrals will be given to the client and every effort will be made to facilitate a smooth transition of services. These referrals do not constitute a personal endorsement of the sources by the counselor. Each client is responsible for providing follow through for their continuity of care.

 

COMPLAINTS: If you have a question concerning your counseling, please discuss this with your counselor or the GraceWorks ministry supervisor. Credentials of all members of the counseling staff are on file in the ministry office, and you may request to view them at any time. Complaints may be formally filed with the counselor’s appropriate governing Board.

 

Customer Service Representative/TX State Board of Examiners
of Licensed Professional Counselors
1100 W 49th Street Austin, TX 78756
1-512-458-7111 or 1-888-963-7111

 

NON-DISCRIMINATION: Green Acres Baptist Church and/or GraceWorks does not discriminate on the basis of race, color, national origin, sex, religion, age, sexual orientation, or disability in the employment or provision of services. Clients are accepted for appointments regardless of religious affiliation or other demographic classifier.

 

Each client will be provided with a copy of this agreement. Please keep it for your records.

This form has been provided as a reference. You will be asked to sign a copy of this form upon your first appointment with Graceworks Counseling Ministry.