Brittney Parmeter’s, MS, PPC, NCC Consent Form

Brittney L. Parmeter, MS, PPC, NCC

Ron Hoopes, LPC, LAT

1101 W Bridge St. Saratoga, WY 82331

307-760-3700

______________________________________________________________

Brittney Parmeter holds a master’s degree in counseling from the University of Wyoming and is provisionally licensed through Wyoming Mental Health Profession Licensing Board 2001 Capitol Ave, Room 105 Cheyenne, WY 82002. Brittney Parmeter abides by and adheres to the ethics set forth by the Wyoming Mental Health Profession Licensing Board and the American Counseling Association. This disclosure statement is required by the Mental Health Professions Licensing Act.

CLIENT/THERAPIST RELATIONSHIP: You and your therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your Therapist can best serve your needs by focusing solely on therapy and avoiding any type of social—including social media—or business relationship. Any type of sexual behavior between client and therapist is never appropriate and will not be condoned. Brittney Parmeter has a provisional license through the state of Wyoming and will be supervised by (supervisor’s name).

RISKS AND BENEFITS: Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling and/or psychotherapy

CONFIDENTIALITY: Brittney Parmeter, MS, PPC, NCC follows all ethical standards prescribed by state and federal law. Per the Wyoming Privileged Communication Statute of 1999, Section 164.512 of the Privacy Rule, and other Wyoming laws that address confidentiality, the following is a list of circumstances in which we are legally held responsible to potentially disclose information without your consent or authorization: a) Abuse or harmful neglect of children, the elderly or disabled or incompetent individuals if known or reasonably suspected including sexual exploitation; AIDS/HIV infection and possible transmission b) Information related to counseling as necessary to defend against a malpractice action brought by a client c) An immediate threat of physical violence against a readily identifiable victim is disclosed d) An immediate threat of self-inflicted harm is disclosed to the counselor e) The patient or client is examined as a result of a court order f) In the context of investigations and hearings brought by the client and conducted by the Wyoming Professional Licensing Board, where violations of this act are at issue g) The validity of a will of a former client is contested h) The client alleges mental or emotional damages in civil litigation or his/her mental or emotional state becomes an issue in any court proceeding concerning child custody or visitation.

CONSENT TO TREATMENT: By signing this Client Information and Consent Form as the Client or Guardian of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. My therapist has gone over this form with me in detail and I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receiving mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time.

 

Signature—Client/Parent                                                                                 Date

 

 

Signature—Spouse/Partner/Parent                                                                  Date

 

I hereby authorize the release of necessary medical information for insurance reimbursement purposes.

 

Client/Parent                                                                                                         Date

 

I authorize the payment of medical benefits to the provider of services.

 

Client/Parent                                                                                                         Date

 

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