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Client Information Form

Women’s InnerFitness & Wellness Center, LLC

Confidential Client Information

Welcome to Women’s InnerFitness & Wellness Center. We want to make the most of each appointment you have with us. One way of doing this is for you to write down some basic information in advance of your first appointment.

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Client-Counselor Limits of Confidentiality

Welcome to Women’s InnerFitness & Wellness Center, LLC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of.

We, as your counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Goals of Counseling

There can be many goals for the counseling relationship. Some of these will be long term goals such as improving the quality of your life, learning to live with mindfulness, and self-actualization. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use. Whatever the goals for counseling, they will be set by you according to what you want to work on in counseling. The counselor may make suggestions on how to reach that goal but you decide where you want to go.

Risks/Benefits of Counseling

Counseling is an intensely personal process which can bring unpleasant memories or emotions to the surface.

There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part.

In order to be most successful, you will have to work on things we discuss outside of sessions.

However, there are many benefits to counseling. Counseling can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages.


Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.


Our providers will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. We may consult with another professional psychologist, social workers, psychiatrist, or physician in order to provide you with the best service. In the event our providers consult with another counselor, no identifying information such as your name would be released. Psychologists and Social Workers are required by law to release information when:

Duty to Warn and Protect

When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

Abuse of Children and Vulnerable Adults

If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

Prenatal Exposure to Controlled Substances

Mental Health Care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.


Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

Insurance Providers

Insurance companies and other third party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

Court Order or Subpoena

Our providers may be required to release some information. In such a case, we will consult with other professionals and limit the release to only what is necessary by law.

Confidentiality and Group Therapy

The nature of group counseling makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that we cannot guarantee that other group members will maintain your confidentiality.

However, we will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. We also has the right to remove any group member from the group should she discover that a group member has violated the confidentiality rule.

Confidentiality and Technology

Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Skype, telephone, email, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Our providers will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. Should a client have concerns about the safety of their email, our providers can arrange to encrypt email communication with you.

Record Keeping

We will keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section.

Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer. Records will be kept either electronically or in a paper file and stored in a locked cabinet in Dr. Price’s office.

Professional Fees

You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash or credit card. If you refuse to pay your debt, our providers reserve the right to use an attorney or collection agency to secure payment.

If you anticipate becoming involved in a court case, our providers recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.

If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Our providers participate in a limited number of insurance plans, so please call your insurance company to see if I am on your insurance plan. With your permission, we will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes. All fees, including co-payments, are expected at the time of our session.

If we are an out-of-network provider with your insurance plan and you pay out-of-pocket for our sessions, you can be reimbursed for our services by submitting your receipt to your insurance company. For clients paying for their own service we accept bank cards, checks, and cash.

Contacting Us

We are often not immediately available by telephone. At these times, you may leave a message on our confidential voice mail and your call will be returned as soon as possible. It typically takes a few hours or a day for non-urgent matters. If you feel you cannot wait for a return call or it is an emergency situation, go to your local hospital or call 911.

We may request client’s email address, however, you have the right to refuse to divulge your email address. We may use email addresses to periodically check in with clients who have ended therapy suddenly. We may also use email addresses to send newsletters with valuable therapeutic information such as tips for depression or relaxation techniques. We may also refer you to blogs and if this is appropriate for the client or may send information through email about information related to mental health and wellness.