Informed Consent Form

Very Important Form! This form reviews your basic rights and policies and procedures of Deirdre Haynes Counseling Services.

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  • Deirdre F. Haynes, Ed.S, NBCT, NCC, LPCS, GCDF
    1030 St. Andrews Road, Suite A-1 Columbia, SC 29210
    Phone: 803-790-2025   Fax: 803-790-7010
    Licensed 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.


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