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Welcome!  It is our desire to ensure that your participation in counseling is a productive and satisfying one.  As licensed professional counselors and social workers, it is our responsibility to safeguard, to the best of our ability, your rights to have competent, confidential, and compassionate care.  In order to facilitate a therapeutic relationship, we have set forth certain information, which will enable you to make an informed consent to counseling.

At Counseling Creations, we strive to establish and maintain a professional relationship with you, the client, characterized by equality and cooperation that allows you to explore your needs, perspectives and goals.  As helpers, we seek to come alongside you in offering encouragement and appropriate empirically sound interventions which may enhance the opportunities for you to experience growth and achieve personal goals.  We encourage between session assignments to practice new intra or inter-relational skills, problem-solving strategies, or to develop additional cognitive and/or behavioral changes which may lead to symptom reduction. There may be outside reading as well which is intended not only to educate, but also to serve as reinforcement of our discussion in session.  We believe that prayer, Bible study, and the presence of the Holy Spirit with in an individual are among the most powerful resources that can be applied, but realize some of our clients may not share this belief.




Your relationship with your counselor is a professional and therapeutic relationship. In order to preserve this relationship, it is important that we limit other types of relationships with you.  Personal and/or business relationships may undermine the effectiveness of the counseling relationship and are unethical.  Out of respect for your privacy, we will not initiate conversations with you in a social setting and will be brief if you initiate contact.


Counseling Services and Risks of Counseling


The number of sessions needed depends on many factors.  It will be important for you to explore your own feelings and thoughts and to try new approaches in order for change to come about.  Often, growth cannot occur until you experience and confront issues that may induce you to feel sadness, sorrow, anxiety, or pain. The success of our work together depends on the quality of the efforts on both of our parts, and the realization that you are responsible for lifestyle choices/changes that may result from therapy.  You have the right to refuse or negotiate modification of any technique that concerns you.  Possible positive or negative effects of entering or not entering counseling and/or using or not using certain techniques may be discussed at any time during the relationship at the initiation of either you or me.  You may bring other family members to a counseling session if you feel it would be helpful or if your counselor recommends it and you agree.




Appointments are made online through the client portal. If you experience difficulties, you may call or text your counselor Monday through Friday between the hours of 8:00 am and 4:00 pm to schedule an appointment or cancel an appointment.  Therapy sessions are approximately 45-55 minutes in length but may be longer if agreed upon by counselor and client. As a client, you are in complete control and may end the relationship at any point, although we do request you participate in a termination session.  We request that the termination include one week in writing.




Cancellations should be received as soon as you are aware that you will miss our scheduled appointment. Due to high demand for counseling services please provide 24 hours-notice so that the appointment can be possible for someone else.  It is preferred that you cancel your appointments on the client portal. Cancellation may be made by phone to your counselor, but it is important that you view the schedule on the client portal to be sure that the appointment has been canceled. If you receive a notice of an appointment that you do not wish to keep, please cancel the appointment online.  As with the norm of the counseling practice, you will be charged a fee for appointments missed as explained in the financial statement.


Phone Consultations


Phone consultations with clients or parents of clients may be needed at times.  If a phone consultation lasts longer than 10 minutes, it is our belief that we should schedule a session in order to discuss the issue. Should you decide to continue a phone consultation, the fees associated with counseling will apply for consultation. Note that if you are paying with insurance, some insurance companies do not cover telephone consultations. The fees will be your responsibility should that be the case.


Payments for Services


Counseling Creation Counselors are professionals, associates and students with supervisors, licensed with the State of Texas or working towards licensure.  There is a set fee for each session that is due prior to the appointment, which is communicated prior to the first session. Please speak to your counselor before the initial session to obtain a clear understanding of the fees. In addition, the required financial agreement form explains further details which will be provided when you sign up for counseling.


Returned check


A $60.00 fee will be assessed for any returned check to cover bank fees.


Letter/Paperwork Fee/Court Appearances

A $75.00 fee will be assessed for short correspondences required for legal matters including, but not limited to, documentation for court, CPS, or lawyers.  Additional fees may apply for other paperwork requested, appearances in court or any other entities.  Longer correspondences will be determined by the time needed to complete the request at a rate of $150.00 to $400.00 per hour. Appearances in court and all events associated with that are billed at $500.00/hour with a 1 hour minimum.


You have the right to confidentiality.  No information will be released without your written consent except as required by law.  Such exceptions to confidentiality include:


1.     We believe you are in imminent danger of hurting yourself or others.

2.     By Texas State Law, we are obligated to report information concerning child and/or elder abuse to the Department of Children and Family Services.

3.     We are required by law to release information such as a court ordered subpoena.

4.     We may need to disclose information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims, as well as, information needed for billing and collection purposes.

5.     If your therapist is a Practicum Student or a Licensed Professional Counselor Associate or a therapist with a temporary license they are under the supervision of a Licensed Professional Counselor Supervisor. During supervision, a therapist may disclose certain information with their respective supervisor who then shares the obligation for confidentiality.

6.     The counseling staff at Counseling Creations also works as a team and your therapist may consult with other therapists and supervisors to provide the best possible care for their clients.  All therapists and supervisors are held to the same confidentiality agreement.


By clicking the box at the end of this information and consent form, you are giving your consent to the counselor to share confidential information with all persons mandated by law and you are also releasing and holding harmless the counselor from any departure from your right of confidentiality that may result.


Under the Health Insurance Portability and Accountability Act (HIPAA), you have Certain rights to privacy regarding protected health information.  You have also been given the HIPAA requirements concerning privacy policies.  This information can and will be used to:

1.     Conduct, plan and direct treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.

2.     Obtain payment from third party payers.

3.     Conduct normal healthcare operations such as quality assessments and physician certifications.

The owner of Counseling Creations is the custodian of the client files.  They are maintained according to HIPAA guidelines and State Law.  In the event of a Counselor’s death, disability, retirement or inability to provide counseling services, the owner of Counseling Creations will possess and maintain the clinical records.


Duty to Warn


In the event that the counselor reasonably believes that you are a danger, physically or emotionally, to yourself or another person, you specifically consent for the counselor to warn the person in danger and to contact any person in a position to prevent harm to yourself or another person, in addition to medical and law enforcement personnel should it be necessary.


This information is to be provided at your request for use by said persons only to prevent harm to yourself or another person. This authorization shall expire upon the termination of your therapy with your counselor.  Understand that you have voluntarily provided this information and be aware that you may withhold this information if you choose.  Please acknowledge that you have the right to revoke this authorization in writing at any time to the extent the undersigned counselor has not taken action in reliance on this authorization. Further acknowledge that even if you possibly still be permitted by law as indicated in the copy of that Notice of Privacy Practices of the undersigned counselor, that you have received and reviewed, you acknowledge that you have been advised by the counselor of the potential of the re-disclosure of your protected health information by the authorized recipients and that it will no longer be protected by the federal Privacy Rule.  I further acknowledge that the treatment provided to you by the counselor was conditioned on your providing authorization.


After-Hour Emergencies


Emergencies are urgent issues requiring immediate action. In event of an emergency, call 911, the Crisis/Suicide number at 800-832-1009 for Montgomery County or 866-970-4770 for Harris County, or go to your local emergency room. In addition, you can Call 988 for the Suicide and Crisis hotline. Stay on the phone with a crisis specialist until suicidal thoughts have subsided.


If you need your counselor during non-business hours, please leave a message on voicemail with your counselor.  Keep in mind your counselor's number is not an emergency number and should not be used as such.  This number can be used to leave a message notifying your counselor that a crisis has occurred. Your therapist is not available 24/7 for crisis calls.  Your call will be returned as soon as possible. Again, this is not an emergency means contact number.  In addition, you can Call 988 for the Suicide and Crisis hotline. 


Goals, Purposes, and Techniques of Therapy


There may be alternative ways to effectively treat the problems you are experiencing.  It is important for you to discuss any questions you may have regarding the treatment recommended by the counselor and to have input into setting the goals of your therapy.  The counselor and client will discuss goals during the initial sessions and throughout therapy. As the therapy progresses, these goals may change. Please note it is impossible for me to guarantee you any specific results regarding counseling outcome.


Legal Actions


The client agrees to hold Counseling Creations, the Counselor and her heirs harmless for any alleged or perceived controversies, damages or claims arising out of the rendering of services agreed upon herein.  However, in the event that the client disregards the terms of this agreement and initiates legal action against the counselor for whatever reason, and the counselor must testify in defense of or otherwise defend self, confidentiality of information will be revealed by client at any time cannot be assumed. It is understood that Counselor will offer whatever information is deemed appropriate and necessary to defend herself against any legal action initiated by the client or as a result of client's actions. 


In addition, associated fees will be due upon receipt of services at the rate of $500.00/hour to Counseling Creations.  This includes review and preparation of documents, debriefing of associates, practicum students and attorneys, commute time to and from locations as needed by the legal action and any other connected activities that require time or expense.

HHS Consumer

If you need to report a privacy violation, file a complaint with Texas Behavioral Health Executive Council calling 800-821-3205 or emailing the council at: › discipline-and-complaints,

 or mail the Texas Behavioral Health Executive Council1801 Congress Ave, Ste. 7.300  Austin, Texas 78701

If you are hearing or speech impaired, you may call 7-1-1 or 800-735-2989 (TTY).

Or you can complete the Form H0404 Privacy Complaint available in English and Spanish and send it to:

The complete Form H0404 may be returned by mail to:

Texas Health and Human Services
Privacy Office
P.O. Box 149030, Mail Code 135-5
Austin, TX 78714-9030

Email to:

For more information go to:

You also may file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, Region VI, 1301 Young St., Suite 1169, Dallas, TX 75202. You can learn more about filing a complaint on the Health Information Privacy Filing a Complaint webpage.


Telephone: 877-378-9869 (toll-free)


Notice of privacy practices 

This notice describes how health information may be used and disclosed and how you can get access to this information. Please review it carefully.  

I. Pledge regarding health information:  

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Counseling Creations. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

1. Make sure that protected health information (“PHI”) that identifies you is kept private.

2. Give you this notice of my legal duties and privacy practices with respect to health information.

3. Follow the terms of the notice that is currently in effect.

4. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.


II. How I may use and disclose health information about you:  

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. Certain uses and disclosures require your authorization: 

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in the Texas Health and Safety code Title 7 subtitle E chapter 611 and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: ​​

a. For my use in treating you.

b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. Certain uses and disclosures do not require you authorization

Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

  3. For health oversight activities, including audits and investigations.

  4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

  5. For law enforcement purposes, including reporting crimes occurring on my premises.

  6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

  9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

  10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. Certain uses and disclosures require you to have the opportunity to object. 

  1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. You have the following rights with respect to your PHI:

  1. The right to request limits on uses and disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

  2. The right to request restrictions for out-of-pocket expenses paid for In full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

  3. The right to choose how I send PHI to you. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

  4. The right to see and get copies of your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

  5. The right to get a list of the disclosures I Have made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

  6. The right to correct or update your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

  7. The right to get a paper or electronic copy of this notice. You have the right get a paper copy of this notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this notice via e-mail, you also have the right to request a paper copy of it.


Effective Date of Notice:

This notice went into effect on 1/1/2021

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

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