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Dinah Wade
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Information Disclosure and Consent Statement 
It is my pleasure to serve you as you seek counseling assistance. This packet contains information you may need to refer to during our counseling relationship. If you have questions about the policies of Grace Counseling Center, please do not hesitate to ask me. 

GENERAL INFORMATION 
I use an approach to counseling which takes into account your spiritual, emotional, physical and social dimensions.  One of your primary tasks will be to determine your goals for counseling. These goals may evolve as we work together.  Whatever your goals, my hope for you is that you grow and mature, reaching a point at which you are able to resolve your problems or develop alternatives for living with these problems.  It is, however, impossible to guarantee any specific results. I work primarily with adults and adolescents, and on occasion with children as young as nine years of age.  I offer individual, marital, family and group therapies.  I work commonly with men and women with the following kinds of issues: depression, marital struggles, recovery from past abuse, anxiety, anger, and compulsions of various types.  Iwill address your individual issues in the context of encouraging your spiritual growth. I have a growing interest and experience with the Enneagram.

QUALIFICATIONS 
I am a Licensed Professional Counselor (LPC) with the state of Texas (license # 14632). I assure you that my services will be rendered in a professional manner consistent with accepted ethical standards as established by the Texas State Board of Examiners of Licensed Professional Counselors. Our office in Boerne is one block off Main Street in the historic downtown area at 211 S. Saunders Street.  My phone number at my office is 830-249-9977, and you may leave a confidential voice mail at that number. I have worked as an independent contractor with counseling centers in the San Antonio area.  I have worked extensively as a therapist for groups and individuals in an acute setting at a psychiatric treatment center in San Antonio.  In this program, I contracted with a group that provided a Christian-based alternative for in-patient and day treatment programs. I hold a Master’s Degree in Counseling from Colorado Christian University (CCU) in Lakewood, Colorado.  Dr. Larry Crabb, a gifted psychologist, speaker and author,directed the counseling program at CCU at that time.  He has written many books including Inside Out, The Silence of Adam, Men and Women, and The Pressure’s Off.  Another distinguished psychologist leading this program was Dr. Dan B. Allender, who has authored such books as The Wounded Heart and Bold Love among many others.  I also hold a Bachelor’s Degree from the U.S. Air Force Academy, Colorado, and another Master’s Degree in Management from Webster University in Illinois. I am a member of the American Association of Christian Counselors and may be found on their referral list of preferred counseling professionals. I am authorized to administer the Gottman marital assessment as a trained Gottman therapist.


CONFIDENTIALITY 
I will keep absolutely confidential anything you say to me  with certain exceptions.  Theseare: (a) you direct me to tell someone else; (b) I determine you are a dangerto yourself or to someone else; (c) a court orders me to disclose certaininformation; or (d) child abuse is taking place.  In this final case, I am required by law to disclose thisinformation to Texas Child Protective Services.    

FINANCIAL POLICIES AND INSURANCE PROCEDURES 
Counseling sessions will be generally 50 minutes in lengthunless otherwise arranged.  I meetwith most of my clients on a weekly basis.  Occasionally, I meet more or less frequently, depending onthe client’s need.  I require fullpayment for counseling at the scheduled appointment in most cases.  Please make your payment at theconclusion of each session unless other arrangements are made.  If you pay by check, please try to fillout your check ahead of time.  Ialso accept Master Card or Visa. 

CANCELLATION POLICY: 
In the event that you will not be able to keep a scheduledappointment, please notify my office at least 24 hours in advance of yourappointment.  If I do not receivesuch advance notice, you will be responsible for paying the full fee forthe session you missed.  If anotherparty supplements your counseling fees, you will be responsible for paying thefee rather than that party.  Pleasebe advised that two consecutive missed sessions without notice or extenuatingcircumstances may constitute a termination of our therapeutic relationship. If you wish to seek full or partial reimbursement for myservices from your health insurance company, I will be happy to provide all thenecessary information your insurance company requires for submitting yourclaim.  Please advise me of yourintentions to file your claim and I will mail invoices to you on a monthlybasis.  If I am in your mental health network, Iwill ask you to complete a form to obtain your insurance information, and fileyour claims in our office.  Healthinsurance companies require that I diagnose and disclose your mental healthcondition to them in accordance with Diagnostic and Statistical Manual (DSM-IV)standards of diagnosis.  Anydiagnosis made will become part of your permanent insurance records.  Please speak with me regarding anyspecific questions concerning these procedures. 

ADDITIONAL INFORMATION 
The process of helping you address troubling areas of yourlife is unique in that it inevitably is the catalyst for one or more personalissues to arise that may cause some degree of personal distress.  The fact that this happens is a normaland natural part of the counseling process.  It is my privilege, as the one you have chosen to beinvolved in this process, to help you work through these problems.  To this end, I anticipate and desire agood and productive professional relationship with you.  The relationship we establish andmaintain will be characterized by mutual respect and openness.  However, in the event that a particulardissatisfaction with my services should arise, I will be very willing todiscuss the nature of your dissatisfaction and make a concerted effort to movetoward a reasonable solution.  Iffor some reason we are unable to arrive at an acceptable solution, I will bewilling to provide you with several possible alternative referral sources.  However, should you believe itnecessary to make a formal complaint regarding your counseling experience, youmay contact the Texas State Board of Examiners of Licensed ProfessionalCounselors in Austin, Texas at the following: 
1100 West 49thStreetAustin, TX78756-3183(512) 834-6658 

EMERGENCIES 
As my client, I ask you to agree to the following guidelinesregarding emergencies.  In theevent of a crisis that you feel you are unable to handle alone, please do thefollowing in the specified order: 
1. Contact a family member for assistance.  If you are unable to resolve the crisisand/or contact a family member, you will: 
2. Contact me at 830-249-9977 if it is during normal business hours, leaving a clear message that youhave an emergency.  If you cannot contact me, you will: 
3. Either call Laurel Ridge Hospital at (210) 491-9400 forassistance or present yourself in person at 17720 Corporate Woods Drive, SanAntonio, Texas.  If you do none ofthe above, you will: 
4. Call “911” for emergency assistance. 

If you have any questions about the information containedherein, or about the counseling process in general, please feel free to ask me.