1 Charleen K. Miele, M.A., LPC Psychotherapist The Sacred Self, LLC

Charleen K. Miele, M.A., LPC Psychotherapist The Sacred Self, LLC 171 Market Square [email protected] Suite 102 Newington, CT 06111 Please read each section of this document carefully and initial each section indicating you have read and understood the contents of that particular section. If there are sections you do not understand, please leave those blank and they will be explained during our first visit. If you are a couple completing these forms, please be sure that both of you initial each section Disclosures and Policies Who is my counselor? Charleen had received her master’s degree in Community Counseling from The University of St. Joseph in West Hartford and her bachelor’s in Religious Studies and Music Education from the same University. She has given particular attention to spirituality and has done extensive work with the teenage population. She has over twenty years of teaching experience, teaching from Pre-‐K through Twelfth grade. She is a certified Fitness Instructor and Personal Trainer and believes in exercising the mind, body, and spirit. Charleen is a member of The American Counseling Association and holds a Connecticut counseling license in accordance with state law. She adheres to the Code of Ethics of the American Counseling Association. Charleen works from the belief that all people are both wounded and healed through human relationship, and sees counseling as an intentional and collaborative relationship with your mental, emotional, and spiritual wholeness as the goal. In addition to her education, she brings to the relationship verbal strength, intelligence, creativity, faith, music, meditation, and sensitivity to the divine and the human spirit. Charleen has a great love and respect for God as the Creator of All. Her love of the mind, body, spirit connection and treating each person as a whole, is an integral part of the therapeutic relationship. Initial here if this section has been read and understood ________ What can counseling do for me? Counseling can help improve your mood, relationships, and functioning, and increase your sense of well-‐being, belonging, and purpose. It can help you understand and accept both yourself and others, strengthen and deepen your relationship with self, others, and God, and face yourself and your life situations with courage and confidence. Initial here if this section has been read and understood _________ 1 What risks and limits does counseling have? Although counseling has been shown to help people, it is not guaranteed to produce a specific result. Counseling helps to empower the client (you) to recognize that you are in control of your decisions, which of course affect your life. Although your counselor is committed to do only what is in your best interest, there is likely to be pain and struggle in the counseling process. You may feel worse before you feel better. Growth often requires the breaking open of issues and accepted opinions, and exploring new opportunities and ways of thinking. You may also want to seek a different form of help at some point, and if that is the case, Charleen will do whatever is possible to assist you in processes that may better assist you. If Charleen believes that you need additional or different help (for example, mediation) she will refer you to a suited professional. Initial here if this section has been read and understood __________ What will counseling be like? Healing and growth in counseling take place through conversation, internal processing, and external behaviors. Counseling is more than just a meeting with an expert. It is a relationship, and involves work both during and between counseling sessions. Conversation: Charleen will ask you to talk honestly with her about your experiences, your thoughts and emotions, and about the counseling process. She will work to communicate in language that makes sense to you. She may use tools of cognitive therapy (relating thoughts and emotions); holistic exercises (involving body, mind and spirit) role-‐play, or meditation techniques in the counseling session. She may also introduce some basic stretching and breathing exercises to encourage mindful and conscious awareness of the body. She will not use any techniques with which you are not in agreement. Initial here if this section has been read and understood __________ Internal Processing: Charleen considers you the expert on your own experience, and much of the therapeutic work is done by you in your thoughts and choices both during and outside the counseling session. In the meeting you are expected to ask questions, express concerns, and bring up topics that are important to you. Outside the meeting, you are expected to make time to focus on your healing and growth and carry out any suggested “assignments” which are intended to enhance same. Charleen may recommend that you obtain books or other resources (or lend them to you from her professional library) to help you in this process. Initial here if this section has been read and understood __________ External Behaviors: During the session, Charleen will help you plan for “homework” to carry out between sessions, if appropriate. These activities or reading materials will be chosen by you and Charleen together to support your healing and growth. You may also decide to make some long-‐term changes to your lifestyle or relationships. At some point, if together you decide it is a viable option, 2 Charleen may invite and encourage you to participate in groups counseling activities. Initial here if this section has been read and understood _________ What about religion? Charleen will ask you about your religious affiliations and spiritual practices, and will help you use them in a genuine and therapeutic way. You are in no way expected to share the same religion as Charleen (or any religion) and every attempt will be made to reconcile your religious beliefs and Charleen’s to a degree that it will best suit you as the client. Charleen will work with your own spiritual resources, and will assist you in clarifying your beliefs if you desire. Charleen will expect you to express any feelings of discomfort regarding a conflict between her beliefs and your. Initial here if this section has been read and understood _________ What is the fee for counseling? Charleen charges a fee that is significantly lower than the average counseling fee at this time. This is due to the fact that until she has completed the State requirements for licensure, she cannot accept Insurance payments for counseling sessions. At this time, Charleen’s fee is $50 for a 50 minute session. Payment for each counseling session should be made by cash, check, or credit card and is due at the beginning of each session. Checks should be made payable to The Sacred Self, LLC. You may request a receipt for your payment. A fee of $25 will be charged each time a check is returned for any reason by your bank. You are expected to pay your regular fee for any appointment missed or cancelled with less than 24 hours notice. If Charleen is asked to prepare documents or to appear in court during your treatment or at any time after it, her regular hourly fee at that date will be charged. Initial here if this section has been read and understood _________ Can my child receive counseling through The Sacred Self, LLC? Charleen has done extensive work with teenage children, but is not a specialist in child therapy, especially with younger children. She is, however, willing to work with you and your child together (or the entire family) for your child’s well-‐
being. Charleen believes that the parent-‐child relationship is the most influential in a child’s world, and she can work with you, the parent, to cope with the demands of your role and to develop skills and strategies for helping your child. Charleen has worked with teens struggling with body image, negative self-‐talk, peer pressure, sexuality, as well as mild depression and bullying. If your child needs more specialized help, Charleen can help you to find the appropriate helper. Initial here if this section has been read and understood _________ In Couple’s Counseling, will each of us be seen individually or always as a couple? In Couple’s Counseling, you will be seen together. If either or both parties are seeing another Counselor for individual work, you may be asked to consider signing a release form so that Charleen can communicate with such counselors if 3 necessary. This will be determined on a case-‐by-‐case basis. Individual work cannot be done with Charleen while Couple’s Counseling is taking place due to confidentiality issues that may potentially complicate or compromise the process. Initial here if this section has been read and understood __________ How much time will counseling take? Each session will last at least 50 minutes. A typical counseling relationship consists of weekly meetings for 6-‐12 weeks. However, some people resolve situational concerns with 3 or 4 sessions, while many others receive help over the course of a year or more to address deep-‐seated issues or complicated situations. Some people return to counseling after time away in order to renew their perspective, address new issues, or simply to get a check-‐up for their mind and soul. Follow-‐up sessions after “successful” counseling is highly recommended. The appropriate time in between termination of counseling and a follow-‐up is different in each case and will be decided together. Sessions are scheduled one at a time. You are expected to attend every scheduled session. If you need to cancel or reschedule, please give Charleen as much notice as possible. If you miss an appointment or cancel with less than 24 hours’ notice, you will be charged your regular fee. Charleen will evaluate your progress with you at regular intervals determined on a case by case basis. She will speak with you about plans to end counseling at the beginning of your treatment, and will make every effort to not end counseling without discussing it with you. If you miss three consecutive appointments, you may be discharged from services. Initial here if this section has been read and understood _________ What if I need help between appointments? For non-‐emergency situations, Charleen will return phone and e-‐mail messages during her next scheduled work day. In order to optimize confidentiality, e-‐mail and texting should be used for scheduling only. If you are considering harming yourself or someone else, or if you need to talk to someone immediately, call 2-‐1-‐1, the Connecticut Information Line. This number is available 24 hours a day, and the operator will connect you with the appropriate hotline. Initial here if this section has been read and understood _________ Will anyone else know I am in therapy? Charleen will keep your personal information, your appointments, and other content confidential except for the following situations in which she is mandated by state law to report to the appropriate person and/or agencies: 1) The client threatens suicide or exhibits suicidal ideation; 2) The client threatens murder, assault, or other physical harm to another person; 3) The therapist suspects child abuse, including but not limited to physical beatings and sexual abuse; 4) The client reports abuse of an elderly person; 5) The client reports sexual exploitation by a therapist. 4 Charleen will ask for your written permission to discuss your information with others if she believes it will benefit you. She may ask for your permission to communicate with your previous counselor (if applicable), your doctor, your religious leader, and/or other professionals who participate in your care. As indicated in the first section of this document, Charleen received professional supervision by a licensed counselor in accordance with Connecticut licensing laws, and may consult with a small group of other professional counselors. When she discusses your case with her supervisor or her colleagues, she will reveal only what is important to make sure you get the best help possible. Initial here if this section has been read and understood _________ What if I am not satisfied with the counseling I receive? You the client have the right to: 1) receive respectful treatment that will be helpful to you; 2) receive a particular type of treatment or end treatment without obligation or harassment; 3) receive therapy in a safe environment, free from sexual, physical, and emotional abuse; 4) report unethical and illegal behavior by a therapist; 5) ask questions about your therapy; 6) request and receive full information about the therapist’s professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations; 7) have written information about fees, methods of payment, insurance reimbursement, number of sessions, substitutions (in cases of vacation and emergencies), and cancellation policies before beginning therapy; 8) refuse electronic recording, but you may request it if you wish; 9) refuse to answer any questions or disclose any information you choose not to reveal; 10) know the limits of confidentiality and the circumstances in which a therapist is legally required to disclose information to others; 11) know if there are supervisors, consultants, students, or others with whom your therapist will discuss your case; 12) request and, in most cases, receive a summary of your file, including the diagnosis, your progress, and type of treatment; 13) request the transfer of a summary of your file to any therapist or agency you choose; 14) receive a second opinion at any other time about your therapy or therapist’s methods; 15) request that the therapist inform you of your progress; 16) have your spiritual beliefs and need respected and addressed in therapy. 17) end the counseling relationship with Charleen, keeping in mind that you should either address the situation in a counseling session and inform Charleen you will not be scheduling a next appointment, or be sure to 5 cancel an already scheduled appointment at least 24 hours prior to that appointment with notification that you will not be continuing the counseling relationship. Initial here if this section has been read and understood _________ What about the written documents associated with my counseling? Charleen will ensure that all records are kept in a secure location and that only authorized persons have access to such records. All written records will be stored following termination of services to endure reasonable future access. Also, records will be maintained in accordance with the state and federal statutes concerning records and will be disposed of in a manner that protects client confidentiality. This is all done in accordance with the American Counseling Association’s Ethical Standards Sections B.6.a., and B.6.g. Initial here if this section has been read and understood _________ Please speak with Charleen about any problem or concern you have with your counseling. She will work with you to resolve it. You may consult the Connecticut Counseling Association at www.ccamain.org or the American Counseling Association at www.counseling.org to learn more about ethical standards of the counseling profession. If you wish to file a complaint you may do so by contacting Connecticut Department of Public Health. Initial here if this section has been read and understood _________ Please note that the next and last page is your actual Consent for Treatment signature page. 6 Charleen K. Miele, M.A., LPC Psychotherapist The Sacred Self, LLC 171 Market Square [email protected] Suite 102 Newington, CT 06111 www.cmieletherapy.com 860-‐614-‐8382 Consent for Treatment We hereby grant our permission for evaluation and counseling according to the disclosures, policies, and terms explained on all attached pages of this document. We are aware that there is a potential for emotional strain and life changes as a result of counseling and we agree to enter the counseling process. We understand that Charleen Miele does not guarantee any particular results or outcomes from the therapy process. We agree to pay $50 for each 50 minute session according to the terms described in this document. We will discuss a counseling plan with Charleen and agree that our treatment is expected to begin with a series of sessions (number to be agreed upon), meeting either weekly or bi-‐weekly. These sessions will consist of a cognitive therapy approach with insight and interpersonal components, with a goal to be determined together with Charleen. Client Name: __________________________________________Date of Birth:________________ Client Signature: _________________________________________ Today’s Date: ________________ Counselor Signature: ___________________________________________________________ Date: _____________________________ 7

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