CLIENT INFORMATION AND CONSENT

Client Information

Contact Information

As evidenced by my signature below, I give consent to Lois Thomson-Bowersock to communicate with me by the following means, using the contact information provided above.

Indicate your preference for each mode of communication by circling “yes” or “no” and writing your initials in the spaces provided. If you prefer not to be contacted at all or to be contacted by an alternative means, please provide specific information and instructions:

Therapist

Lois Thomson-Bowersock is a Licensed Chemical Dependency Counselor, a Level II Alcohol & Drug Counselor, an Internationally Certified Alcohol & Drug Counselor and a Certified Experiential Therapist, engaged in private practice providing mental health care, addiction counseling and educational services to clients directly.

Educational & Support Group Services

Educational and group support services are intended to enhance your individual recovery process using educational resources and group dynamics to help you to better understand your situation and feelings and move toward resolving your difficulties. The therapist will use her professional experience to make observations about situations, provide relevant education and facilitate the group process to appropriately present suggestions for new ways to approach identified problems. It will be important for you to explore your own feelings, thoughts and to try new approaches in order for change to occur.

Lois Thomson-Bowersock retains the right and responsibility to screen participants prior to admission to the group. She also has the ethical and professional obligation to discharge any participants from the group she deems inappropriate due to the medical or mental health well-being of the individual, or for the group as a whole. In the event of such a discharge, Lois Thomson-Bowersock will provide suitable referral resources and recommendations.

Group Meeting Time, Location & Fees

The group will meet on Wednesday evenings from 6:30 – 7:45 PM. All group meetings, unless otherwise agreed upon in advance, will be conducted in the conference room, located at:

1733 Woodstead Court, Suite 101
The Woodlands, Texas 77380

It is suggested that participants make group attendance a priority. Because integrity and accountability are key elements in the recovery process please call 281-419-5255 and leave a voice mail message if you are unable to attend a specific meeting.

While there is no established fee for group attendance, a voluntary payment of $15.00 per group is suggested to help offset administrative costs. However, participants are under are under no obligation to pay the suggested fee. Fees for this group are being offered at a discounted amount as a community service. It is the intention of Lois Thomson-Bowersock to provide individuals with an exceptional quality, professionally facilitated process, education and support group. At all times the group participants are encouraged to respect the value of the services provided and conduct themselves accordingly with diligence and commitment to the recovery process.

Emergency Contact Information

In the event that Lois Thomson-Bowersock reasonably believes that I am in danger, physically or emotionally, to myself or another person, I specifically consent her to warn the person in danger and to contact the following persons, in addition to medical and law enforcement personnel:

After Hours Emergencies

Emergencies are urgent issues requiring immediate action. You may contact Lois Thomson-Bowersock by cell-phone at 281-782-6755. In the event of an emergency requiring immediate psychiatric or medical attention please telephone 911 and/or obtain emergency services at your nearest hospital. In the event suspected overdoses of mood-altering substances such as alcohol, prescription medications and/or illicit drugs, you are advised to seek immediate emergency medical services.

After Hours Emergencies 281-782-6755

Confidentiality Between Therapist & Client

Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include, but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; AIDS/HIV infection and possible transmission; criminal prosecutions; child custody cases suits in which the mental health of a party is in the issue; situations where the therapist has a duty to disclose, or where, in the therapists judgment, it is necessary to warn or disclose; fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist; or the filing of a complaint with the licensing board. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss the matter further. By signing this information and consent form, you are giving your consent to Lois Thomson-Bowersock to share confidential information with all persons mandated by law and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for these services, and you are also releasing and holding Lois Thomson-Bowersock harmless from any departure from your right of confidentiality that may result.

Although it is the goal of Lois Thomson-Bowersock to protect the confidentiality of your records and group participation, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure of your records or testimony is required by law, you will be responsible for and shall pay the costs involved in producing the records and the therapist’s normal hourly rate for the time involved in preparing for and giving testimony. Lois Thomson-Bowersock normally charges a fee of $100.00 per hour for office services performed during regular working hours, Monday thru Thursday, $140.00 per hour for evening (after 6:00 pm), Friday or Saturday appointments, and $ 175.00 per hour any services performed outside of the office. In addition, the client will be responsible for reimbursing the therapist for clerical and travel expenses incurred to perform the necessary services. Such payments are to be made at the time or prior to the time the services are rendered by the therapist.

Lois Thomson-Bowersock is required by law to maintain the privacy of your protected health information (PHI) and to provide you with notice of your privacy rights and the therapist’s legal duties and privacy practices with respect to your PHI. Lois Thomson-Bowersock is required to abide by the terms of the Notice of Privacy Practices with respect to your PHI but reserve the right to change the terms of the notice and make the new notice provisions effective for all PHI that she maintains. The therapist will provide you with a copy of the revised notice sent by regular mail to the last address you have provided to the therapist for this communication purpose. The Notice of Privacy describes how mental health information about you may be used and disclosed and how you can get access to this information. You are advised to read it carefully.

Group Confidentiality

As evidenced by my initials and signature below, I acknowledge that, with group therapy, there is risk of disclosure of confidential information by persons in the group to individuals outside the group.

I agree that I will not disclose information learned by me during the course of any group session and I will protect each participant’s right to confidentiality. (client’s initials indicate acceptance of the terms of this statement.)
_______ Initials

I agree to hold Lois Thomson-Bowersock & Associates harmless from any claims or liability resulting from my disclosure of confidential information to a third party outside of the group session. (client’s initials indicate acceptance of the terms of this statement.)
_______ Initials

I agree not to hold Lois Thomson-Bowersock & Associates responsible, and release her/them from same, for/from any claims or liability that I could assert as a result of disclosure of my confidential information by co-participants in my group therapy sessions. (client’s initials indicate acceptance of the terms of this statement.)
_______ Initials

Consent to Group Therapy

As evidenced by my signature below, I voluntarily agree to participate in group therapy with Lois Thomson-Bowersock

I understand and agree that I will participate in the planning of my care, treatment, or services, and that I may stop such care, treatment or services that I receive through Lois Thomson-Bowersock at any time.

By signing this Client Information and Consent form, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

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