Professional Disclosure Statement and Informed Consent

Welcome to Colin O’Grady, Licensed Professional Counseling, LLC. This document contains important information related to our professional services and business policies. Please take the time to read this carefully and please bring any questions to my attention at your next session. Signing this document represents an agreement between you and Colin O’Grady, LPC to move forward in the process of counseling.

Qualifications and Experience

I am a practicing Licensed Professional Counselor (LPC PC#006161) in Pennsylvania for 7 plus years and a former school counselor for 12 years (PA K-12 Certificate #1062783). I earned my Masters of Education in School Counseling Grades 7-12 in 2007 and received my K-6 certification and Licensure Certification in 2010. I have been working in the helping professions since 2003, and providing counseling since 2004. I have counseling experience in private practice, as a School Counselor in grades 7-12 and in community agency settings.

Counseling Approach and Client/Counselor Roles

I provide individual, couples, family, and group counseling services to adults, adolescents and children while integrating techniques from various therapies including (not limited to) Cognitive Behavioral, Gestalt, and Person Centered therapy. I take a person-centered, strengths-based approach, collaborating with clients to cultivate skills and resources designed to improve the quality of life. We will explore your experiences and relationships and work toward your goals. My role is to listen in a non-judgmental way, ask questions, and provide feedback. You are the expert on your life and have the ability to work to change your experience. We may agree to “homework” to help you achieve your goals. Psychotherapy is not like a medical doctor appointment. It differs in that you will need to actively work on aspects of your life, in session and in the world, that are in need of improvement.

Practice Fees (per session), Billing and Payments

  • Initial Evaluation: $150
  • Individual Psychotherapy: $125
  • Family Therapy: $125
  • Group Therapy: $80
  • Late/Cancelation Fee: $60

Payment for all services will be due at the time services are rendered. This includes insurance co-payments and deductibles and private payment. Individual sessions are 60 minutes in duration. All new clients in the practice will have an initial assessment to explore needs, goals, and fit with counselor. I do accept some health insurance products. Should your insurance change at any time and does not cover the cost of psychotherapy, you will be financially responsible for the associated fees. It is your responsibility to be aware of the mental health coverage associated with your health insurance plan. This can be completed by contacting the customer service department at your insurance provider. We would be more than willing to assist you in understanding this information, should the need arise. Any telephone call, report preparation, clinical evaluations, treatment summaries, FMLA, Disability and letter writing requests will be billed at a fee of $150 per hour. Please be advised that insurance companies do not cover any expense for the therapist time necessary to complete these special reports. In the event that you become involved in legal proceedings that require your therapist’s participation or attendance, you will be expected to pay for the time even if your therapist is called to testify by another party. Due to the complexities of legal involvement, we will charge $300 per hour for preparation and attendance at any legal proceedings. When attending, fees will apply from the time I
leave my office to the time I complete my testimony and return to my office. If 24 hour notice is not provided for cancelled or rescheduled court dates, there will be a cancellation fee of $300.

Risks and Benefits of Counseling

The counseling process can be difficult at times as we grapple with certain issues and feelings, but it also has the potential to be very rewarding. The process of making change can involve risks such as dealing with traumatic events, painful emotions, and the unpredictable impacts of change on our lives. Counseling is a process that takes time, self-assessment, commitment, and an openness to change and self-growth. While counseling is beneficial for most, I am unable to provide any guarantees. I look forward to collaborating with you on your journey. You may ask questions about the process or end counseling at any time. We will regularly assess your goals and the effectiveness of our sessions. During our work together, you may be assessed for a diagnosis, which becomes a permanent part of your client record. Please review your rights under HIPAA regulations. Feel free to ask questions at any time.

Ethics and Competency

As a Licensed Professional Counselor in the Commonwealth of Pennsylvania, I am obligated by the ethical codes and laws relevant to counseling. Part of my ethical obligation is to only provide services to clients who I am competent to serve. If I determine that your needs are outside of my expertise or scope of practice, or at your request, I can make referrals to other mental health providers. All counseling comes to an end at some point, which is called termination. Should ongoing therapy be needed at that time, we will work together to find appropriate services to meet your needs. Please see ethical codes at http://www.counseling.org/ethics.

Dual Relationships

I will not enter into personal (dual) relationships with clients outside of professional counseling services. This boundary continues even after counseling is terminated. This is an ethical obligation that benefits you by allowing me to serve as a counselor rather than a friend. I do not initiate contact with clients in public places or communicate online or through social networking sites to protect this boundary and your confidentiality. Occasionally, I may share some of my experiences in sessions when it may be beneficial, but our focus will be on your experiences.

Confidentiality

Information discussed in our counseling sessions will remain confidential, except in the circumstances below that are mandated by law or by the ethical guidelines of the Pennsylvania Board of Licensed Professional Counselors and the American Counseling Association. I may break confidentiality:

  1. If you make written request for the release of information. Also, if you request for diagnosis information (if applicable) to be released on a receipt for payment purposes to an insurance company.
  2. If there is a risk of serious or foreseeable harm to any person (yourself or another person).
  3. If you disclose a life-threatening, communicable disease, I may be obligated to alert an at-risk third party.
  4. If I have reason to suspect that a minor-aged, developmentally disabled, or an elderly person is in danger of being abused or neglected. I am legally obligated to report this to the Department of Social Services.
  5. If I am ordered to release confidential information by a court of law via subpoena.
  6. If I need to share information with another professional for consultation, with a health care provider treating you in an emergency, or with other mental health professionals when necessary to coordinate your care. These professionals are also obligated to maintain confidentiality.

Emergencies, Phone Sessions, and Email

In the event of an emergency, please dial 911 or go to the emergency room. If you cannot reach me immediately by telephone during a crisis, you or your family should contact the Resolve Crisis Network at 1-888-796-8226. As a private practitioner, I am not on call or available 24 hours a day. Often, I am with clients or away from my phone. I generally try to return messages within 24 hours with the exception of weekends and holidays/vacations. If you need a higher level of services than I am able to provide as a private practitioner, I can offer a referral to a more appropriate agency. I generally do not offer phone sessions except in crisis situations, teleconferencing is a preferred method. Teleconferencing sessions, if necessary, will be billed to you at the same rate as your regular session. Communication via email will be brief and not contain confidential information as this method of communication offers limited
appropriate dialogue in an emergency situation. Emergency Contact Information If there is an emergency during the time we are working together, or if I become concerned about your personal safety, I am required by law and the ethics of my profession to contact someone close to you. By completing this section, I authorize Colin O’Grady, LPC to contact my designated emergency contact person in the event of an emergency or if he suspects threat of harm to self or others. Please write the name and contact information of your chosen contact person in the space provided below: