PHOENIX’S INFORMED CONSENT AND PRACTICE POLICIES

Phoenix Jackson, Licensed Marriage and Family Therapist #110164

 Light Heart Therapy, 1434 Third St. Suite C., Napa, Ca 94559 

Phoenix@LightHeartTherapy.com ; 707-387-1282 

General Information: The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with your therapist. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

Beginning therapy is a big step, and it’s important to know a little bit about what you’re choosing, who you’re working with, and what you can expect – both from the process of therapy itself, as well as from me and this organization. Below are some things to consider before we begin…

Your Right to Refuse Services: Therapy values client autonomy and self-determination. You get to decide to enter therapy, and it’s always your right to end therapy, at your will.

The Course of Therapy: Therapy can be a beautiful process of expressing yourself without being judged, getting to know yourself better, and working toward goals that bring you closer to the life you want to have. However, therapy can also be a challenging process. At a pace that works for you, you will be encouraged to be an observer of your life, your thoughts, your emotions, and your bodily sensations. This can be difficult at times, and feeling less than enthusiastic about the therapeutic process is absolutely normal. You are encouraged to bring up any hesitancy or concerns you have about therapy and our work together during our sessions so that we can make the necessary changes to our course of work or otherwise support you through the process. If at any time you feel that we are not a good therapist-client match, your therapist will do my best to refer you to a therapist that might be a better fit for you.

Alternative Treatments: Therapy isn’t the only thing out there that might help! Medication, changes in diet or exercise, acupuncture, massage, good friends, other therapeutic modalities, spiritual practices, and pets are just a few things that also may help you.

No Guarantees: It’s always possible that therapy won’t be helpful to you! It’s not the best treatment approach for everyone, and it’s important to notice this together if therapy begins to feel stagnant.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/her/their self in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses, as well as financial abuse (fraud, theft, etc).

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

In addition, your therapist may share non-identifying client information with consultants and in case conferences with professional therapists and healthcare professionals as permitted by law.

Occasionally, your therapist may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If you (client) and therapist see each other accidentally outside of the therapy office, your therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge your therapist first, they will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office unless explicit arrangements are made for out-of-office therapy.

My Qualifications and Specialization: Phoenix Jackson has earned a masters degree in Somatic Psychology from John F. Kennedy University in Pleasant Hill. This means that they acknowledge the connection between the body and psychology and use body awareness in addition to cognitive insight to support clients in working toward their goals.

Clinical Licensure Status and Professional Corporation and Ownership Information: Phoenix Jackson Family Therapy & Consultation, Inc. DBA Light Heart Therapy is a professional corporation in California. Phoenix Jackson is the sole owner of Phoenix Jackson Family Therapy & Consultation, Inc. DBA Light Heart Therapy. Phoenix Jackson is a Licensed Marriage and Family Therapist.

Unexpected therapist absence. In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for an Executor to inform you of my status and ensure your continued care in accordance with your needs. The Executor of my Professional Will is Colette Mercier, and the Secondary Executor (i.e., the person who would take on the Executor role if the named Executor is unavailable) is Lawanda Jackson. You authorize the Executor and Secondary Executor to access your treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice.

NOTICE TO CLIENTS: The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Fees and Payments: Phoenix Jackson Family Therapy & Consultation, Inc. strives to offer fees that are equivalent to competency and experience. A 50-minute individual session with me costs $225.00 and a 75-minute couples session costs $240.00. Arrangements can be made for longer sessions; please note that the fee will be adjusted accordingly at the rate of $50.00 per 15-minute increment. Payment is due at the beginning of the scheduled session, unless we make alternate arrangements. There is a $30.00 administrative fee for returned checks, and two returned checks will eliminate checks as an option for payment. Payment can be made by cash, Zelle, check (these first three are most preferred), and debit/credit card. Please make checks payable to “Light Heart Therapy.” Subsidized payments (Loveland Foundation, NQTTCN, 100 Black Men, Lotus Therapy Fund, etc) are considered on a case by case basis. No refunds are given for sessions that have already taken place.

Fees may be periodically increased (maximum of two times per year of working together usually in June and/or January) to reflect the rising cost of business. If you receive a sliding scale or reduced rate, your fee may increase more frequently. You will be given a minimum 30-day notice of any increase in fees and you will have the opportunity to discuss any impacts it may have on your therapy.

Appointments and Cancellation Policy: Consistency is very important to the therapeutic process. If you need to reschedule or cancel an appointment, please provide at least a 24-hour notice of cancellation to avoid being charged for the session. If you do not give a 24-hour notice, you will be charged the full cost of a session. To cancel a session, we recommend you log in to our secure client portal via Simple Practice to cancel the session directly. Your therapist will get a notification as soon as this happens. To reschedule during any particular week, you will be able to view and request appointments with your therapist in the client portal or you can discuss rescheduling in advance, which is preferred, during your session.