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Client Information

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( If client is a minor, the legal guardian must enter their email address below. )

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Terms and Policy

Informed Consent
I hereby consent to engaging in in-person, distance therapy or "teletherapy" with Stephanie A. Adams as part of my own psychotherapy and/or for a minor of whom I am the parent or legal guardian.

I understand that...

...the psychotherapy and/or counseling will be conducted by a qualified
psychotherapist/counselor. Stephanie A. Adams is licensed in the state of Texas as a professional counselor, license number 65450. The status of this professional license can be confirmed at any time by visiting the Texas Department of Health website.

...consultations, test results and disclosures between Stephanie Adams and myself will be held in confidence within the restrictions of Texas state law. These exceptions to
confidentially include cases in which:

- illegal activity is occurring (such as physical or sexual abuse); 

- I present a credible plan to threaten my own life

- the purpose of counseling is to obtain a court evaluation

- legal action regarding the therapy itself (such as a malpractice suit) is in progress.

...I have a right to access my medical information and copies of medical records in accordance with Texas law.

...the therapist is a consultant and resource professional. Her suggestions may be
freely accepted or rejected by the client. Therefore, decisions made during and after
therapy are the responsibility of the client. The client has the right to end treatment at any time without penalty.

...the dissemination of any personally identifiable images or information from a teletherapy interaction to researchers or other entities shall not occur without my written consent.

... as a non-physician therapist, Stephanie Adams will not prescribe medication.

... there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. It is possible that technical problems might at times cause messages not to be received. It is also possible that misunderstandings due to lack of visual or verbal cues may occur. Turnaround time for asynchronous (such as email) communications cannot be immediate.

...teletherapy-based based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a psychotherapist who can provide such services in my area.

... there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some rare cases may even get worse. I am intended to benefit from therapy, but that results cannot be guaranteed or assured.

...full fee will be charged for all sessions where I no-show or late cancel with
less than twenty-four (24) hours notice given. (Example: If your appointment is at 4 pm on Wednesday, your counselor must be notified of your desire to cancel or reschedule by 4 pm Tuesday. Email notification that is time-stamped before 24 hours will be acceptable on weekends.)

I affirm that I have read all the conditions above and that they have been fully
explained to my satisfaction. I understand and agree to them freely and without

( Type Full Name )
Payment Policy
Payment must be received before therapy is conducted. Before booking a session, you will be required to submit valid credit card information and release permission to charge this card on the day of your session, or as payment for a session or for a no-show without 24 hours notice.

Your card will not be charged for any other reason in is stored securely. At such a time as therapy is ended, you can request that your card information be deleted from secure storage.
( Type Full Name )
Technology Failure Policy
These terms apply to online counseling and therapy or outside communication in accompaniment to face-to-face sessions.

If our communication or therapy is ever interrupted by technology failure, I will call you back immediately if we are conducting telephone therapy/communication. If we are conducting any other type of online therapy, I will contact you via telephone as quickly as possible to work out alternative arrangements or postpone. If your network is down, please call me immediately (I recommend writing down my number somewhere offline) in order that I not charge you for the missed session. At this time, we may choose to either postpone or conduct our therapy under a different medium. Even if you are primarily an email or chat-based client, please keep my phone number handy for these extraordinary circumstances. My number is 817.677.8336. (Please leave a detailed message if I cannot answer, I am the only one who has access to my voicemail.)

Text & email policy: I am able to receive text messages at the above phone number and email at but neither text message nor email is a secure way to communicate. My recommendation is to stick to telephone calls or the secure messaging feature on this client portal. If you choose to use text or email communication, please keep personally identifying information to a minimum for your own protection.
( Type Full Name )
Social Media Policy
Use of social media in context of our counseling relationship presents certain risks to your privacy and well-being. These risks include (but are not limited to):
- Exposing our counselor-client relationship to others.
- Subjecting private conversations to the public if either of our social media profiles are hacked.
- Causing you to feel our relationship has become more personal than you are comfortable with.
- Impacting my ability to provide a "blank slate" for you in our professional relationship.

Because of these risks to you, I've implemented the following policies:
- I do not accept friend requests from clients on social media. If you send me a friend request, I will ignore it to protect our relationship from being exposed.
- I do not follow my clients on social media. By ethical standards that would be considered a violation of your privacy for me to view your social media profiles without express permission. If you feel viewing your social media profiles would be important to our clinical work together, I am happy to do so if you sign a release to allow me to do that.
- Since communication via social media is not secure, I will not send or respond to messages via social media. (Facebook messages, DM on Twitter, etc.) If you send me a message via social media, I will try to contact you via phone or the secure client portal to follow up!
- I do not post my business on review sites like Yelp. If you come across a listing for my business that offers you the opportunity to review or star my business, I request that you do not rate it, even if your review is positive! In essence, your rating my business exposes the fact that you are in counseling to the entire internet, and that is no one's business but yours. I appreciate any desire to boost my reputation, but request that you tell your friends one-on-one rather than posting it publicly. And of course, if you have any concerns, I'd appreciate the chance to hear about it in person so I can help you resolve it.
- You are free to "follow" me on any social media sites (but not required to do so) as anyone can follow me and it doesn't identify you as my client. Please be aware that I have disabled messaging on my practice Facebook page, ( to protect you from Facebook seeing your messages.
( Type Full Name )