Informed Consent Statement
Mount Comfort Counselling Services
P. O. Box 3381, Fayetteville AR 72702
4257 N. Gabel Dr, Suite 2B, Fayetteville AR 72703
Glenda Davis, MSC, LMFT, LPC – Therapist
Counseling Services and You: In signing your name below, you agree to receive counseling from a licensed professional counselor. It is expected that you will be benefited by these services, and that you will participate fully in order to gain these benefits. Your counselor will be prayerfully seeking the best possible type of counseling for your specific issues and seeking the Lord’s help with each counseling session. However, you should be made aware that there is always a risk that the process may involve substantial discomfort on the way to more positive outcomes. You are free to discontinue services at any time, but it is urged that you discuss that decision with your therapist.
Confidentiality and Protected Health Information: When you receive mental health care, including treatment for substance abuse, information related to that care may be more protected than other forms of health information. Communications with a therapist in treatment are privileged and may not be disclosed without your permission, except as required by law. For example, mental health professionals are mandated reporters if they suspect child abuse and may have to breach confidentiality if you appear to pose an imminent danger to yourself or others, in order to reduce the likelihood of harm to you or others.
A complete copy of the HIPPA (Health Insurance Portability and Accountability Act) information sheet has been provided to you as a separate document. Your signature below attests that you have received a copy of that document.
Counselor Incapacitation or Termination of Practice and your Records: Counseling records will be maintained at the 4257 N. Gabel Drive Office. In the event that your counselor should become incapacitated, die or terminate the practice, John Michael Huddleston, will be responsible for provided an appropriate referral to another licensed or pastoral counselor. He will also be the custodian of your records. You may contact him by calling the office of the Mt. Comfort Church of Christ, 479-442-9171 or by calling 479-466-0634.
Financial Arrangements: You have the right to be informed of the cost of services rendered to you. Payment of $100/session is due in full at the time services are rendered unless previous arrangements have been made. If you wish to use insurance, please inform your therapist at the first session. If you are a member of the Mt. Comfort Church of Christ, counseling sessions will be provided on a sliding fee scale based on household size and income. The actual scale is available upon request. Payment options and special assistance are available to clients who qualify. If Mt. Comfort is paying for any part of the services, your name and general situation may be revealed to the elder in charge of the counseling program, Huston Givens. We require that you notify the therapist at least 24 hours in advance should you wish to cancel or reschedule an appointment; failure to do so could result in fees being charged in full. Clients who arrive 15 minutes late will be required to reschedule and pay for the missed session.
I HAVE READ, UNDERSTOOD AND AGREE TO CONSENT MYSELF AND/OR MY CHILD(REN) FOR TREATMENT BY MT. COMFORT COUNSELING SERVICES. I GIVE MY PERMISSION FOR MY MENTAL HEALTH CLINICIAN TO LEAVE A BRIEF VOICE MAIL FOR MESSAGE ON MY PHONE, IF NECESSARY.
Signature of client, parent or legal guardian
Signature of client/spouse Date
Signature of mental health clinician, Glenda Davis, M.S.C, LMFT, LPC
Modifications to above: