**If you have questions or concerns you would like to address before signing, feel free to contact me by calling me @
1-800-880-1605 EXT. 7 Or email me at RDMurphyHughes@gmail.com I will return your message as soon as possible.
PLEASANT PRINT OUT OUT, READ THE INFO, SIGN, AND RETURN BY EITHER
E-MAIL, OR UPS MAIL.
otherwise known as the client, agree to receive Life/Relationship Counseling /Coaching Services, and/or Parent Education Services for either *myself (circle if yourself) or *for my minor child (circle if services are for your minor child) - either then known as the client, put name of person this applies to or the person for whom I have Guardianship/Power of Health Care Attorney (then known as the client), print that person's name here___________________________________, by Renee D. Murphy-Hughes, M.A., FPT, LPC - WI.
I understand and agree that counseling services are clinical or diagnostic in nature, only IF Ms. Murphy-Hughes is providing services to a client within her state of licensure - Wisconsin and that she is representing herself as a Licensed Professional Counselor OR is able to practice outside the State of WI. for the purpose of providing Distance Counseling which is included in her licensure as long she provides it from her state of licensure - WI. Should any litigation unfortunately take place, it would be heard in the State of the Counselor.
I understand and agree that any of the venues I choose to receive my services in, will be priced according to the Levels and Fees Tab posted on this website, unless otherwise agreed on by Ms. Murphy-Hughes and the Client in writing. Ms. Murphy-Hughes will assist me with my overall goals or concerns that are within her area of expertise by using such methods as: Effective Goal Setting Techniques, Providing Necessary Education (including reading or other exercises between appointments), Teaching Effective Communication Skills for both Personal and Professional Use, Exploring the tenants of Cognitive-Behavioral Therapy, Family Systems Therapy, Rogerian (Humanistic) and Existential Therapy. She will help you to refine decision making skills, assist the Client to discover their strengths and challenges and help them to balance their skills, strengths, talents, and interests to find their best vision of themselves. Self-Assessments are often used and are meant for the Client to become clear on their needs, goals, and any clinical diagnoses that may need to be addressed as well as to help Ms. Murphy-Hughes to offer her best support and guidance and make referrals as needed and able.
I understand and agree that any personal information outside of basic data is generally not accessed by the IT personnel and/or Assistants but if something is shared for the continuance of delivery of services it will be kept confidential within this office per the notice of Confidentiality and Privacy (HIPPA) which is provided and is also posted on the website. Otherwise, any information will be shared only with a signed Consent to Release form from you, the Client, as required by law of Ms. Murphy-Hughes as a Mandated Reporter.
Usual open hours for Face-to-Face and Distance Services are listed on this website: www.OurJourneyThroughLife.org I understand that Ms. Murphy-Hughes will try to make other accommodations when an appointment time outside of her usual schedule is needed. I also understand that she is under no obligation to do so and that this is considered a courtesy service. **I understand and accept responsibility for providing 24 hrs notice in advance of any missed appointment via any venue (phone, internet, f/f), otherwise I agree that at her sole discretion Ms. Murphy-Hughes may charge me a $25 cancellation fee prior to the next session or when invoiced, whichever comes first, if it was not unavoidable. This Professional also holds the right to terminate services if there is a pattern of cancellations without notice such as 3 appointments in a row are missed. The Counselor will make every attempt possible to also provide 24 hrs notice to cancel and will ask for a phone # and e-mail address in order to be able to reach the Client in a timely manner. This includes Internet problems which may cause the need for cancellation or rescheduling which is out of Ms. Murphy-Hughes control.
Ms. Murphy-Hughes always encourages feedback from the Client(s) so any changes can be made that would make the Client's experience as successful as possible. She asks that the Client talk to her about any concerns, so she can make the appropriate adjustments to get on the same page and to assist the Client to continue to participate in sessions and gain the maximum benefit.
By Signing Below, I also am attesting that I have read, and I am aware of the background and expertise of Ms. Murphy-Hughes and therefore the scope of her services within and outside of the State of Wisconsin. I also understand and agree to her policies regarding scheduling, cancellation of appointments, rate of payment, and payment methods listed here on her website: www.OurJourneyThroughLife.org I further understand that payment information is collected upfront at least 1 hr. before a session is started and is processed through PayPal.
By signing below I agree it is my responsibility to pay for all professional services rendered by Ms. Murphy-Hughes.
PRINTED NAME: ________________________________________________________
SIGNATURE OF CLIENT OR RESPONSIBLE ADULT: ___________________________________________________________
DATE OF CONSENT: _____________________________
**DATE OF BIRTH OF MINOR IF SIGNING AS PARENT/RESPONSIBLE ADULT: ______________________________________
This Service Agreement is valid for one (1) year from the date of signature unless client puts in a different date or rescinds this in writing and it is received and recorded. Anything released prior to that cannot be rescinded.
Date of Expiration of Consent:___________________________________________
All Rights Reserved