Deirdre F. Haynes, Ed.S, NBCT, NCC, LPCS, GCDF1030 St. Andrews Road, Suite A-1 Columbia, SC 29210Phone: 803-790-2025 Fax: 803-790-7010E-mail: email@example.comWebsite: http://dhaynestherapy.comLicensed Professional Counselor (#5425), State of South Carolina
Thank you for choosing Deirdre Haynes Counseling Services. Your appointment will take approximately 50 minutes. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of my policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and I will try my best to give you all the information you need.
Deirdre Haynes, Ed.S has earned a Bachelor of Arts Degree in English, a Master’s Degree in Secondary Guidance and an Education Specialist degree in K-12 School Counseling from South Carolina State University and the University of South Carolina. She is licensed by the State of South Carolina as a Licensed Professional Counselor. She has over 10 years of clinical experience in treating adolescents, adults and families using individual and family therapy. Deirdre Haynes, Ed.S practices standard Cognitive Behavioral, Client Centered, Solution Based and Reality therapy for most conditions. Although other treatment approaches are used depending on the person or condition. Treatment practices, philosophy and plan limitations and risks will be discussed with you today.
Your verbal communication and clinical records are strictly confidential except for: a) information (diagnosis and dates of service) shared with your insurance company to process your claims, b) information you and/or your child or children report about physical, sexual abuse or elder abuse. (SC State Law states that it is mandatory for me to report this to the Department of Children and Family Services), c) where you sign a release of information to have specific information shared and d) if you provide information that informs me that you are in danger of harming yourself or others e) information necessary for case supervision or consultation and f) or when required by law. If an emergency situation for which the client or their guardian feels immediate attention is necessary, please call the office to speak with me. If I am unable to return your call within 15 minutes, the client or guardian understands that they are to contact the emergency services in the community (911) for those services. Deirdre Haynes Counseling Services will follow-up those emergency services with standard counseling and support to the client or the client's family. E-mail, text messages and social networking sites are not confidential and I may not be able to respond.
You agree that your electronic submission of this application serves as your consent and agreement to be bound by the terms and conditions of Deirdre Haynes Counseling Services. You further agree that the electronic submission has the same effect as though you physically signed this agreement and that this electronic submission qualifies as your signature for all intents and purposes.
I/We have read and received a copy of the, Notice of Privacy Practices and Client Rights document.
NOTE: Complete ONLY if you have a child receiving treatment.
CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS:
maybe treated as a client by Deirdre Haynes Counseling Services. It is understood that children over the age of 12 have confidentiality protected by law. At times it may be necessary to schedule appointments during school hours. We ask for your cooperation to provide the most timely treatment for you and your children. This consent to treat expires at the end of treatment or if revoked in writing.