Consent Form

Agreement with: Ann Duvall
Phone: 202.599.1495
E-Mail: ann@annduvall.com


DISCLOSURE STATEMENT & PHILOSOPHY

Ann Duvall is a Licensed Professional Counselor in Washington DC with counseling experience in mental and spiritual health providing care to adults and adolescents. Her approach to treatment is person-centered, allowing clients to determine their needs and goals to transform life’s challenges and pain towards solutions and while she serves as a guide to help one towards a higher level of awareness and self-acceptance.


Ann integrates various theoretical orientations in psychology, along with body- centered therapies, to incorporate the idea of the “wise self” or “self” which strives towards unity or wholeness. She focuses on various psychological tenets in clinical work however finds that when choices are made from the centered wisdom of the “real self” clients lead a values driven life which lends itself to healing. In addition to traditional therapies, she incorporates techniques in the treatment room ranging from expressive and experiential therapies, and mind- body medicine including mindfulness meditation, Qigong, and stress reduction skills. Clinical areas of specialization include spirituality/religion and mental health, general mental health issues, interpersonal/relationship issues, grief and loss, career and adjustment issues.


PROCESS OF COUNSELING/EVALUATION

Participation in counseling can result in a number of benefits to you, including improving interpersonal relationships and resolving specific concerns that led you to seek counseling, and requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I encourage your feedback and views on your counseling, progress, and other aspects of the counseling and request that you respond openly and honestly.

I do NOT provide custody evaluations, medication or prescription recommendations, or legal advice, as these are beyond the scope of my practice and expertise.
Discussion of Treatment Plan
Within a reasonable period of time after the initiation of treatment, I will discuss and reach a mutual agreement regarding the focus and goals of counseling. If you have any unanswered questions about any of the methods used in the course of your counseling, or about the treatment plan, please ask and I will discuss and answer your concerns as fully as possible. You also have the right to ask about other treatments and their risks and benefits. You have the right to terminate counseling at any time. If you could benefit from any treatments that I do not provide, I will assist you in obtaining those treatments.


CONFIDENTIALITY

All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.

 

When Disclosure Is Required By Law

Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, to others, to property, or when a client’s family member communicates to me that the client presents a danger to self or to others. If I become concerned about your personal safety or the possibility of you injuring someone else, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you provide as emergency contact.

Emergencies

I am not available 24/7 to address clinical concerns. If you need immediate guidance or just somebody to talk to outside of our scheduled visits, please call the National Lifeline at 1-800-273-TALK and/or if you feel suicidal please dial 911.

If there is an emergency during the time we are working together or I become concerned about your personal safety, I am required to contact someone close to you therefore please provide the name and contact information of your chosen contact person in the space below.

Supervision/Consultation & Confidentiality

I engage in supervision and consultation as part of a commitment to best practice. When your care is discussed with a supervisor or colleague your identity and privacy are protected.

Communication

It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Please notify me if you decide to avoid or limit in any way the use of any or all devices. Therapeutic services will not be provided via e-mail or text and cannot be used for emergencies. Email and texts may be used to exchange information only or to schedule or modify appointments.

Records and Your Right to Review Them

Both the law and the standards of my profession require that I keep appropriate treatment records for at least 7 years. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case I will provide the records to an appropriate mental health professional of your choice. When more than one client is involved in treatment I will release records only with the signed authorizations from all the adults involved in the treatment.


EMERGENCY PROCEDURES

If you have an emergency and need immediate help, go to your nearest hospital emergency room or call 911. If you need to contact me between sessions, please leave a message on my cell phone (202.599.1495) and I will return your call as soon as possible. You may e-mail or text me, aware that confidentiality cannot be ensured. Please do not use e-mail or text for emergencies.


I give my permission to be contacted at the following telephone numbers:

Permission to leave message on Cell Phone?
Permission to send text message to cell phone?
Permission to leave message on Home Phone?
Permission to leave message on Work Phone?

FEES/CANCELLATION POLICY/SESSION FREQUENCY

 

Fees & Payment

I ask clients to pay me at the end of each session. Additional consultation services (e.g., extended telephone sessions, report writing, etc.) will be charged at the same rate, unless agreed upon otherwise. I do not participate in insurance nor can these services be billed to an insurance company. My standard fee for a counseling session of 50 minutes is $180.00. I accept cash, checks, Square Venmo and Paypal as payment options.

 

Cancellation

We commit to begin and end our sessions on time. If you wish to change your appointment, you will let me know at least 48 hours in advance by emailing me and calling/ texting me. I will not send reminders for the scheduled session times. Unless you cancel more than 48 hours in advance, I will still request the full fee payment. In the case of true emergencies, no fee will be charged for cancellations less than 48 hours in advance.

 

Frequency of Sessions

The primary treatment service involves one-on-one counseling and the frequency of sessions will vary based on the client’s presenting issue(s) and need.

Sessions are typically scheduled weekly or biweekly.

I have read the above Policies, Informed Consent & Disclosure Statement. I understand them and agree to comply with them.