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Life’s Light in Counseling, Inc. Shannon West, LPC, AADC, IAADC

INFORMED CONSENT

  This form is intended to answer your questions, concerns and inform you of my policies. Please ask me about any questions or concerns you may still have. My goal is to work with you to bring light into your situation by listening to you, helping you identify your goals and developing a plan to help you reach your goals. That may include an appropriate referral, teaching skills and/or giving you different ways to view situations in your life, improve communication skills and recognize healthy/unhealthy behaviors and thought patterns. 

  Licensure and Certifications for Shannon West

Licensed Professional Counselor, L.P.C.

Advanced Alcohol Drug Counselor, A.A.D.C.

Internationally Certified Advanced Alcohol & Drug Counselor, I.C.A.A.D.C.

Board Approved Supervisor for L.A.C.'s

Technology-Assisted Counselor

Technology-Assisted Board Approved Supervisor for L.A.C.'s

Theoretical and Populations this professional serves- I assist adults, adolescents and children. I provide individual and relationship counseling. Clients who are coping with their own or a family members’ addictions or mental health issues/disorders. relationship or self-esteem concerns, and other disorders. My primary theoretical orientation is Cognitive- Behavioral Therapy; however, I often use other orientations as the need arises. The first couple of sessions we will work together to identify and establish your goals for treatment and develop an agreed upon plan to reach your goals. Sometimes, changes for treatment will be agreed upon as progress of treatment is evaluated. This is normal and to be expected. Often times, symptoms can worsen at the onset of treatment then become much less and/or subside. This is also normal as one begins the mental health treatment process. Treatment is most productive and successful if you talk as openly as you can about your thoughts and feelings that you are experiencing and want to change. I encourage and invite you to talk about any disappointments or troubles you experience within our counseling process. Your concerns will be addressed.   

Confidentiality Confidentiality is maintained as part of the counseling process in adherence with the ethical standards of the American Counseling Association. Your written authorization is required for any release of information or records.  

Limits of Confidentiality Communication between a client and a counselor is protected by law, and I can only release information about our therapy sessions to others with your written permission. There are a few exceptions you need to be aware of:

1. If you file a complaint or lawsuit against me as your therapist, I may legally disclose relevant information regarding our work together in order to defend myself.

2. If I have reason to believe that a child, senior citizen, or vulnerable adult is being neglected or abused, the situation has to be reported to the appropriate state agency. 3. If I believe you present a clear and substantial danger of harm to yourself or another/others, I will take protective actions by reporting this danger. These may include contacting family members, seeking hospitalization for you, notifying any potential victim(s), and notifying the police. 

Charges for services and Payment Policy- Payment is expected at the time of service unless prior arrangements have been made and agreed upon.

Methods of payment include: checks made out to Shannon West, cash or Credit Card or Debit card. Payments can also be accepted through this website through PayPal.

Receipts for payment are provided upon request.

Each Initial counseling session is $200.00 (90 min). Each subsequent session is $200.00 (50-60 min).

Technology-Assisted Counseling/Consulting includes Doxy.me, Phone or Email and is provided at the rate of $30.00 every 15 min. The charge is rounded up to the next 15 min block of time.

Cancellation Policy- If you need to cancel or change an appointment, please give me at least 24 hours notice. If you cannot give me 24 hours notice and the reason for cancellation is not urgent or emergent then you (not your insurance) will be responsible for the fee in full for the amount of time and service you were scheduled for. This is standard practice among professionals in this field. I reserve the right to recommend another counselor who may be more suited to your needs, should you miss more than two sessions.  

By signing below you indicate that you have reviewed, understand, and are in agreement with the policies of this practice statement.

Client Signature _________________________ Date ___________