Mark Beck M.Div., M.Ed.,

Licensed Professional Counselor (VA)

Licensed Mental Health Counselor (FL)

Informed Consent and Confidentiality Agreement

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Overview

Welcome to Pairs Care Counseling, LLC. This document contains important information about my professional services and business policies. Please read it carefully and ask any questions you might have at any time. When you sign this document, it will represent an agreement between us. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. No one can guarantee what you will experience.

 

Background

My professional background is two-fold. I earned my Master of Divinity degree from Southeastern Baptist Theological Seminary in Wake Forest, NC in 1984 and have served as pastor to churches in North Carolina and Virginia. In 1998, I earned a Master of Education degree from Lynchburg College in Lynchburg, VA and have been a Licensed Professional Counselor in Virginia since 2001 (LPC #0701003291). I have been a private practice therapist part time from 2000-2015 and full-time since then. I became a Licensed Mental Health Counselor in Florida in 2016 (LMHC #MH14402) and established Pairs Care Counseling, LLC in Inverness in 2017, where I focus exclusively on couples therapy. You can verify my license in Virginia at https://dhp.virginiainteractive.org/Lookup/Index and in Florida at www.Floridahealth.gov.

 

I have professional training in both cognitive-behavioral and solution focused therapy and, as a couples therapist, I practice a combination of Gottman Method Couples Therapy and Emotionally Focused Therapy (EFT). Gottman Method Therapy is based on Drs. John and Julie Gottman's research that began in the 1970's and continues to this day (see www.gottman.com). His empirically validated research has focused on what makes relationships succeed or fail.

 

EFT complements Gottman Method Therapy well and focuses on strengthening a couple's emotional connection. It is also empirically validated and was devised by Dr. Sue Johnson (see www.ICEEFT.com) in the 1980's.

 

Your Counseling

In order for our work to be productive and clinically sound, I will not conduct therapy with any client who appears to be intoxicated or under the influence of any substance. I will also ask clients to be on time. Without previous notice, a session that does not begin within 15 minutes of the appointment time will be considered a missed session. If you miss a session or cancel less than 24 hours prior to the session, you will be billed for the session. I will try to accommodate unforeseen circumstances. Your first three therapy sessions are about assessment and helping me to understand your relationship. In the first session, we will talk about the history of your relationship and your areas of concern. In the next two sessions, I usually meet with each of you individually to learn your individual stories and hear your thoughts and feelings. I will also provide you with a questionnaire that you can complete online between sessions through the Gottman Institute. This process is fully HIPAA (Health Insurance and Portability and Accountability Act of 1996) compliant. The nominal cost is not included in your session fee. Our first three sessions and the online assessments will help us devise goals and a plan for your therapy, which I will share with you.

 

The length of the therapy will be a mutual decision between us, based upon your needs and goals. Neither Gottman Method Therapy nor EFT are long term models and most couples can expect to spend between ten and twenty sessions in therapy. Again, this may be shorter or longer, depending on any number of circumstances. You are free to raise concerns about your therapy at any time. Couples therapy involves skills and interventions that you must use and practice. The extent to which you invest in and practice these skills will in large part determine how long and how successful your therapy proves to be. Initially, we will plan to meet weekly; sessions are fifty (50) minutes.

 

In most cases, I will meet with you as a couple. However, there may be times when I or you might wish to meet individually. In that event, I will almost always spend an approximately equal time in session subsequently with your partner in order to maintain a proper balance to our work. Later, or if circumstances dictate, we will meet less frequently to give you time to practice your new skills. We may terminate therapy whenever you wish, but if you terminate prematurely, you may find that the problems that brought you to therapy get worse or relapse. Also, before stopping therapy, it would be helpful to have at least one session to summarize what you've accomplished and to draw our work to a close. Research suggests that follow-up sessions at six months, one year, 18 months and two years are beneficial. This is up to you, of course.

 

While I have undergone training in the Gottman Method Couples Therapy and EFT, please know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. Neither the Gottman Institute, the International Center for Excellence in Emotionally Focused Therapy, nor their agents bear any responsibility for my services. Occasionally in therapy, individual issues arise that need to be addressed in greater depth. In such cases, I may refer the individual to another mental health professional for individual work. My policy is to do only couples therapy and to maintain clear boundaries. However, it may be helpful to communicate with the other provider, with your permission, to provide effective continuity of care.

 

While I do not file insurance (most plans do not cover couples therapy), I will assist you in preparing any documentation you may need to seek reimbursement from your insurance company. Payment is due at time of service. Occasionally, there will be additional fees, of which you would be apprised beforehand. For example, in the very unlikely event that I must testify in court proceedings for or about you, I will bill you for my professional time, even if I am requested to testify by another party. If at any time, you become unable to pay for your sessions, we will discuss options for satisfying your balance. Otherwise, this may necessitate termination.

 

The laws and standards of my profession require that I keep treatment records. You are entitled to access those records, unless I believe that seeing them would be emotionally damaging to you. These are professional records; they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in session with me so that we can discuss the contents, or I will send them to a mental health professional of your choice. Clients will be charged an appropriate fee at my regular hourly rate for any time spent outside of session preparing information requests.

 

In certain circumstances, it may be necessary for me to render a diagnosis, which constitutes a constellation of symptoms characterizing a certain presentation or problem pattern. In such cases, I use the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V).

 

Privacy

As a therapy client, the law affords you the right to privacy. Face-to-face sessions in my office take place behind a closed door. Your information is stored via a secure client portal, which is HIPAA compliant and provides a business associate agreement. You will find the link to it on my website (www.PairsCare.com). This secure client portal uses point-to-point, federally approved encryption. The only information of yours that is stored on any electronic device of mine is your phone number (on my phone), and your email address (on my computer), if you have emailed me. My phone and computer are both password protected. Any paper with your personal information is kept in a locked cabinet behind a locked door. I will only seek information from you that contributes to your counseling.

 

Privacy also includes your right to confidentiality. That is, I will tell no one that you are a client or anything about my work with you without your expressed, written permission, which you may revoke in writing at any time. In my service to you, I may, on occasion, wish to communicate with other professionals you may be seeing, but again, only with your permission. If I see you in public or any other context, I will not acknowledge that you are a client and our professional relationship will remain confidential.

 

Most importantly, you need to know that confidentiality has limits. They are broad, but you should know that I am bound, in certain circumstances, to disclose certain information even without your consent. The following are cases in point:

If I have good reason to believe that you are an imminent risk of harm to yourself or others, or cannot care adequately for yourself as a result of a mental illness, I must report that to whomever can help guarantee your safety (emergency services, law enforcement, family members), if you are unwilling or unable to do so.

If I have reason to believe that you may harm someone else, I must report that to the individual and to law enforcement to assure the safety of your intended victim.

If I have reason to believe that you are abusing a child or dependent adult, I must report that to Child or Adult Protective Services immediately.

I may legally break confidentiality if I am audited or investigated by a local, state or federal board or agency.

If you are involved in legal action that places your psychological condition before the court, you forfeit your right to confidentiality in matters before the court.

 

I will always work to avoid violating confidentiality. In any case, I will always only provide information relevant to the issue at hand, provide it to the fewest parties necessary and notify you of my course of action as soon as possible.

 

Another matter of confidentiality pertains to the nature of couple therapy. By definition, the client is the couple; I will not keep secrets between partners when those secrets involve some current or ongoing violation of trust in the relationship. If you tell me something in an individual session that I feel your partner should know, we will discuss the best path forward from there, but I will not maintain secrets that constitute betrayal or collusion. If you communicate with me outside of session, your partner will know in our next joint session.

 

Note also that forensic evaluations, such as providing recommendations regarding parenting fitness or child custody are beyond the scope of my practice; I do not provide that service.

 

Accessibility Between Sessions 

I can be reached by telephone at 434-841-0538 or email. If you call, you will usually need to leave a message. I will make every effort to return your call as soon as possible. After hours, weekends, holidays, etc, it may take me longer to respond. Should you have a serious emergency, your local emergency room is available to you. If I am away for an extended period of time, I will provide emergency coverage with another competent counselor. My email address is MarkBeck@PairsCare.com. However, this email is not encrypted and, thus, could be compromised. A more secure way to email me is through the secure client portal (where you registered initially). This portal stores all email correspondence, but it is fully encrypted.

 

Please refrain from making contact with me using any social media messaging systems such as Facebook Messenger or Twitter. These methods are not secure and I cannot watch them closely for important messages from clients. To protect your confidentiality, my policy is not to “friend” or “follow” clients or former clients on social media. Also, please refrain from creating reviews of my services online. Online reviews are for the public to see and would therefore jeopardize your privacy.

 

Counseling, by its very nature is based on trust. I desire to establish and maintain a positive, fruitful relationship with you. I subscribe to the American Counseling Association Code of Ethics and Standards of Practice. Should you feel at any time unsatisfied with our work, or worse, if you feel that your rights have been violated, hopefully we can discuss and resolve it. If you seek further recourse, you may contact the Florida Department of Health at www.floridahealth.gov.