|
GCC INFORMED CONSENT FORM
Stayton United Methodist Church
1450 Fern Ridge Road SE Stayton, Oregon 97383
Phone (503) 769-4108 e:mail: [email protected] Web Address: http://www.wvi.com/~fumcs
Gregory J. Johanson, M.Div., Ph.D.
Minister of Church & Community Counseling
Director, Grace Counseling Center
INFORMED CONSENT
Please read and sign, keeping one copy for yourself, and returning one to me.
1. Description of services: My background is in psychotherapy and clinical psychology as well as theology. (A vitae is available on request.) As a Licensed Professional Counselor, Pastoral Psychotherapist, professor and psychotherapy trainer I have training in and use a number of therapeutic modalities with individuals, couples, groups, families, and organizations. In particular, I am a Certified Hakomi Therapist and a Founding Trainer of the Hakomi Institute. Hakomi Therapy is an eclectic approach to psychotherapy that specializes in integrating the use of contemplative states of awareness, non-violence, and the mind-body interface in the support of healing and/or personal growth. I also incorporate the family therapy methods (highly congruent with Hakomi in terms of their essential regard for safety and respect of organic wisdom) of Metaframeworks and Internal Family Systems, of which I am also a trainer. I abide the ethical codes of the American Psychological Association, and the American Association of Pastoral Counselors.
If I had to put one name on the integrative nature of the work I do, I would call it “Clinical Spirituality;” clinical because we are dealing with human issues, and spirituality because I believe that Sprit (which is called by many names) is an essential aspect of being human; an aspect that has been highlighted in the recent emphasis in psychology on the essential self, core self, or soul.
I consider entering into a therapeutic alliance with each other a sacred trust on both our parts. While I bring professional expertise to our sessions together, my primary skill is in offering a relationship and an empowering process within which you can gracefully explore issues that are important to you. I will help you mine the wisdom of your own experience in relation to the predicaments and possibilities of your life, while integrating important resources where appropriate, as opposed to my "changing," "curing," or making life decisions for you. Responsibility for your life is always with you, even while we are intimately exploring new possibilities together. Everything we do is always with your full awareness. Nothing will be done without your approval, and your sense of feeling safe and right about it. You are invited and encouraged at all times to openly discuss with me any question or concern you might have about the process in which we are collaborating. You retain the right to terminate the process at any point.
2. Confidentiality: What you say and do in sessions with me will be kept in strict confidence, as a pastoral trust. Information concerning you, even the fact that I am seeing you at all, will not be shared with other persons without your permission. However, as a professional, it is my responsibility to seek consultation and supervision with other professionals in relation to my work. Through this consent form I am asking your permission to share aspects of our time together with appropriate consultants, who are likewise sworn to confidentiality. Also, if there is reason for me to believe that you are likely to do physical harm to yourself or another person, then it is my responsibility to notify the appropriate persons or authorities. Finally, seeking third-party payments puts one’s diagnosis on record in those systems.
3. Length, frequency, and number of sessions: All these factors vary according to the individual situation. Your own opinion is normally a fundamental guide of decisions regarding these matters. For some individuals it is not uncommon to meet once every other week for a one and a half-hour session. For couples or families, meeting every other week for two-hour sessions is not uncommon. Sessions with children are usually shorter. Some issues lend themselves to short-term exploration (1-12 sessions), some to long-term.
4. Fees: I do not believe one can charge for healing or healing relationships. However, helping professionals need to be supported in their life and continuing education so that they can be available to others. I provide services on a sliding scale, which means that those who are able to pay more are in community with those who pay less. The cost per session (normally one and a half-hours) is determined by dividing your gross yearly income by 750. For instance, if your yearly income were $20,000, the fee would be $30, if your income were $80,000, the fee would be $120. The upper limit is $300. I can only work with a sliding scale if payment is made as services are provided. Fees will be adjusted up or down according to fluctuations in your income.
Those who are not able to pay a minimum of $112 per session are asked to donate an hour of community service. Those who pay at the higher end of the scale may reduce their fee by $50/per hour for every hour of community service, to a minimum of $112.
I am also available to you on the phone. If you choose to call me, the first fifteen minutes are free. Fifteen to thirty minute phone consultations will be billed at the rate of one quarter of a session; thirty to forty-five minutes at a one-half session rate; forty-five to sixty minutes at a three-quarter session rate; and over 60 minutes at a full session rate.
5. Canceled appointments: Once we agree to a specific meeting time, you are assuming responsibility for that slot until we choose to terminate. Cancellations are not workable since I cannot fill that period with an appointment for anyone else, because that would make it unavailable to you again. Appointments missed due to inclement weather, in which it is dangerous to travel, are billed at one-third the agreed rate, which balances the loss of personal growth to you, and the loss of livelihood to me. It is always possible to negotiate the availability of alternate times when circumstances change.
6. Other services: I am only one option for professional services in this community. I will assist you in seeking another source of psychotherapeutic help if/when either you or I consider a referral to be in your best interests. It is desirable that you check out other practitioners before you consent to begin with me. Since many variables are important in one's life, I may recommend referral to other practitioners such as clinical nutritionists, body-workers, movement or exercise therapists, groups for special issues, vocational counseling specialists, faith community leaders, etc. These referrals could be appropriate before, during, or after our time together.
CONSENT: I have read the preceding two pages, and have discussed with Greg Johanson to my satisfaction the kind of process I can expect to enter into with him. I give my assent to do so, and agree to pay $_____________ for each scheduled appointment, as well as ____ hours of community service. I understand that my signing this form does notcommit me to a binding contract, but merely indicates my willingness, with informed consent, to begin a consultation process with him.
Name __________________________________________________________________________
Address __________________________________________________________________________
__________________________________________________________________________
Phone Work(___)_____________ Home (___)_____________ Email ___________________
_______________________________________________ _______________________
Signature Date
Possible Forms of Community Service
Participate in religious congregational service projects
Write someone shut-in
Write someone in armed forces
Write ???
Visit someone shut-in
Visit in a prison
Telephone someone shut-in or isolated
Be a Big Brother/Sister
Teach a class to youth
Teach a class to seniors
Teach a class to a special needs group
Be a coach or assistant
Be a youth group leader in your neighborhood/congregation
Help at a food pantry
Help with homeless programs
Help at a non-profit second hand store
Provide transportation to someone for doctor’s visit
Provide transportation for shopping, visiting, etc.
Clean up a section of roadway
Do chores for someone disabled
Walk/ride/swim/run in a charitable event
Organize a charitable event
Do volunteer work in a hospital or service agency
Be a volunteer guide in a museum, park, etc.
Cook for someone in need
Help with remodeling or maintenance needs for someone in need
Be a volunteer camp counselor or support person
Read for someone young, old, ill, etc.
Teach reading to someone
Teach math, business, etc. to someone in need
Do consultation with a non-profit
Do consultation with someone in need
Provide a professional service pro-bono
http://www.oregonvolunteers.org/
http://www.oregon.gov/OPRD/VOL/index.shtml
http://www.volunteermatch.org/
http://earthshare-oregon.org/volunteer/
_______________________________
______________________________
BEGINNING INFORMATION
Please use as much or as little space as feels right to you to respond to the following questions. Consider doing it in the service of your own self-reflection as much as you are doing it to inform me. It would be helpful if you could get this to me before our first session.
1. What is bringing you to consult with someone at this time?
2. What do you think is most affecting your current situation: a) internal factors,
b) external events, or c) both? Please explain.
- What are you presently doing that is satisfying to you?
4. What hopes and dreams give, or would give you, excitement about the future?
5. Who are the significant others in your life at this time (family, work, friends, organizations, etc.)
6. What healing processes have you participated in to this point? What has been helpful?
7. Do you have a spiritual tradition that is meaningful to you?
8. (for couples) How long have you been in this relationship? What stages have you gone through with each other to this point? How is your partner alike or not alike others with whom you have been in significant relationship? What repetitive and less than satisfactory cycles of interaction do you tend to find yourselves in?
|
Printer friendly