Informed Consent – Deirdre Haynes Counseling Services

Deirdre F. Haynes, Ed.S, LPC, LPCS
1030 St. Andrews Road, Suite A-1 Columbia, SC 29210
Phone: 803-790-2025 Fax: 803-790-7010
E-mail: dhaynes@dhaynestherapy.com
Website: http://dhaynestherapy.com
Licensed Professional Counselor, 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 that 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 and as a Licensed Professional Counselor Supervisor. She has over 10 years of clinical experience in treating adolescents, adults and families using individual and family therapy. Deirdre Haynes, Ed.S, LPC, LPCS 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 10 minutes, the client or guardian understands that they are strongly advised to contact community emergency services (911) or go to the nearest emergency room for those emergency services. Deirdre Haynes Counseling Services will follow up those emergency services with standard counseling and support to the client. E-mail, text messages, and social networking sites are not confidential. I will NOT discuss any counseling-related topics other than scheduling an appointment on the forms of media..

May I inform your physician?
- No
- Yes
Physician Name:
First Last
Clinic Name:
Clinic Phone:
Clinic Address:
Street Address Address Line 2 City State / Province / Region
Date
MM slash DD slash YYYY
Electronic Signature:
First Last
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.

Notice of Privacy Practices & Client Rights:
I/We have read and received a copy of the, Notice of Privacy Practices and Client Rights document.
May we contact you at home?
- No
- Yes
May we contact you at work?
- No
- Yes
May we contact you by cell?
- No
- Yes
How may we contact you?

NOTE: Complete ONLY if you have a child receiving treatment.

CONSENT FOR TREATMENT OF CHILDREN OR ADOLESCENTS:
I/We consent that

(enter child's name).
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.

* My signature below indicates that I have read, understand, and agree with the content of the entire DHCS Informed Consent Form. **My signature below indicates that I have reviewed and received the Fee Schedule, Client Rights Form, and the HIPPA Notice of Private Practices Form. ***My signature indicates that I am aware that this signature is valid for the duration of the counseling relationship.
Client's Electronic Signature:
First Middle Initial Last
Date
MM slash DD slash YYYY
Verified by:
First Last
Position:
You agree that the electronic submission of your Informed Consent Form indicates agreement to the terms and conditions of this agreement and is a manifestation of your intent to be bound by such terms and conditions. You further agree that such electronic submission has the same effect as though you physically signed this agreement and that such electronic submission qualifies as your signature for all purposes.
Signature

Informed Consent Form

Step 1 of 5

Notice of Privacy Practices & Client Rights:

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