Page 1



Practice Policies and Client Information/Consent Document


Thank you for considering First Light Counseling and Psychological Services (“First Light”) for your therapy and/or assessment needs. This document contains important information about our professional services and business policies.


Dr. Brian Haworth first embarked on his career in mental health at the Ohio State University, where he majored in Psychology and received his B.A in 1993. He gained valuable experience working with the severely mentally ill by working as a case manager for Community Support Services in Akron, Ohio before heading to Colorado Christian University to earn his Master’s in Counseling in 1996. After returning to Ohio and providing counseling services to a private high school in Cleveland, Ohio for two years, he returned to his studies at Wheaton College, where he earned his doctorate in Clinical Psychology in 2004. Dr. Haworth did his post-doctoral hours at Vanderbilt, and went on to join the faculty in the Department of Psychiatry there. He has been licensed as a psychologist with Health Service Provider designation by the state of Tennessee since 2005. Following this great experience, he went on to become the Vice President and Clinical Director of the Psychological and Counseling Division at Highlands Professional Group in 2008. Dr. Haworth founded First Light Counseling and Psychological Services in 2014, and is so excited to offer services in his hometown area of Franklin/Brentwood. In addition to his education and clinical training, Brian’s work is informed by his role as a husband, father, and by his Christian faith. While some clients might share this faith background and welcome the inclusion of this component in the therapy, this is not assumed and Brian does not wish for any client to feel uncomfortable if they do not care to speak from that frame. It is Brian’s hope that he could be helpful to clients regardless of their own background and/or differences from himself, but he is glad to offer referral recommendations should you feel more comfortable working with someone different.



The Process of Therapy and/or Assessment:

Dr. Haworth enjoys working with teens (and parents), couples, and adults. He uses a mix of different theoretical orientations and techniques in therapy, with all sharing the common factor of being methods that have been shown to be effective through research. These include, but are not limited to: Motivational Interviewing, Cognitive Interpersonal Therapy, Dialectical Behavior Therapy, and Emotionally-Focused Therapy. While therapy cannot be guaranteed to yield positive or intended results for everyone, Dr. Haworth does his best to find the approach that fits best for each client/couple that he sees. Some clients might present difficulties that fall out of his area of skill or comfort level, and in those cases he will try to offer other clinicians as good treatment options.

Growing pains: As is common with many areas of life, the process towards

healing can sometimes be uncomfortable. Taking a closer look at events, relationships, and our selves can be challenging, and might bring up some difficult feelings, such as increased sadness, anger, and/or regret. It is important to discuss these feelings with Dr. Haworth as they arise, so the two of you can discuss the reasons for them, and ways to cope with them as you are getting back to health.

What to expect: Your initial session will involve an evaluation of your needs

and is normally scheduled for 90 minutes. At the end of the initial session, Dr. Haworth will be able to provide you with some first impressions of what therapy may include and will begin to develop a treatment plan with you. Sessions after the initial evaluation are typically scheduled for 50 minutes. Therapy sessions usually occur on a weekly basis during the heart of the time that the work is being done. This might shift to once every two weeks once good progress has been made and problem areas have begun to improve. Sessions can also be adjusted to twice weekly during crisis periods. Good therapy always requires openness and good feedback, so Dr. Haworth will encourage you to bring up any questions or concerns that you have about your treatment at any time. Progress will be reviewed periodically, and adjustments to the treatment plan will be made as needed. Deciding when to stop your work together is meant to be a mutual process. Before you stop, you and Dr. Haworth will discuss how you will know if or when to come back or whether a regularly scheduled "check-in" might work best for you. If it is not possible for you to phase out of therapy, Dr. Haworth requests that you

3   schedule at least one consolidation session in order to have good closure on the therapy process.

Fees and Payment: Dr. Haworth’s standard fee for an initial evaluation, typically scheduled for 90-minutes, is $225. The standard fee for a 50-minute session for individuals, couples, and families is $165. These charges will not change without 60 days written notice. This fee may be paid by credit/debit card, health savings account card, cash, or check, and is to be paid at the start of each session. The full fee will still be required if you are late, and the session will necessarily end on time so as not to run over into the next person’s session.

Financial Assistance: In accordance with his personal morals and the ethical guidelines for psychologists put forth by the American Psychological Association, Dr. Haworth offers four reduced fee or pro bono slots per week to assist those who would otherwise be unable to receive services by him. If his fee is a concern, please discuss it with him. If he is unable to accommodate your financial situation, he will provide you with referrals.

Insurance: Dr. Haworth does not currently accept insurance. If you have mental health benefits through your insurance plan, you might be eligible for out of network benefits. Out of network benefits may cover some of the fees for services with Dr. Haworth, but it is your responsibility to verify the specifics of your coverage. Please remember that the services are provided and charged to you, not your insurance company, so you are responsible for payment. Fees you pay for therapy services that are not reimbursed by insurance may be deductible as medical expenses if you itemize deductions on your tax return. Dr. Haworth will provide you with a monthly billing statement for reimbursement if you wish to submit it to your insurance company. This monthly statement is your receipt for tax or insurance purposes.

Making Appointments/Cancellations: Please call the First Light Counseling and

Psychological Services office number at (615) 861-2222 to schedule your appointment. Leave a confidential voicemail regarding your request and your call will be returned as promptly as possible. Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be

4   charged to your credit/debit card that for sessions missed without such notification. For this reason, all clients must leave a credit/debit card number on file upon beginning treatment. Most insurance companies do not reimburse for missed sessions. Therefore, you will be responsible for the amount billed under those circumstances.

Contacting Dr. Haworth: When you need to contact Dr. Haworth for any

reason, these are the most effective ways to get in touch in a reasonable amount of time: • By phone @ (615) 861-2222. You may leave messages on the voicemail. This is the preferred method of contact, as Dr. Haworth utilizes a service that has signed a Business Associate’s Agreement to assure confidentiality/privacy. • As a secondary option, you may contact Dr. Haworth by email at However, though the service that handles Dr. Haworth’s emails also has signed a Business Associate’s Agreement to assure confidentiality/privacy on their part, Dr. Haworth cannot assure confidentiality or privacy regarding your email service provider and/or the devices by which you access it. If, after having considered these risks you decide to contact Dr. Haworth by email, he will assume that you are consenting for him to reply to the email address – whether it is secure or not. Emails are best used for messages or questions regarding appointment time, and not about personal or clinical information.

Response Time: Dr. Haworth might not be able to respond to your messages and calls immediately. For voicemails and other messages, you can expect a response within 24 hours, with the exceptions of weekends/holidays. Be aware that there may be times when Dr. Haworth is unable to receive or respond to messages, such as when out of cellular range or out of town. He alerts his clients as to times that he is anticipating being out of town for extended periods of time (i.e., vacation, workshops), and lets them know where to turn if assistance is needed during that time.

Emergency Contact: Please know that Dr. Haworth and First Light Counseling and Psychological Services do not provide twenty-four (24) hour crisis or emergency crisis services. If you are ever experiencing a crisis and you require an immediate response or a response before we can get back to you, please call 911, or the mental health crisis line (1-855-274-7471 for adults or

5 1-866-791-9221 for minors). Alternatively, if you are able to safely transport yourself, go to the nearest hospital emergency room for assistance.

Social Media: Dr. Haworth does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). It is his belief that adding clients as friends or contacts on these sites can compromise your confidentiality. It may also blur the boundaries of your therapeutic relationship. If you have questions about this, please bring them up in session with Dr. Haworth. First Light Counseling and Psychological Services keeps a Facebook Page to allow people to share its blog posts and practice updates with other Facebook users. All of the information shared on this page is also available on the First Light Counseling and Psychological Services website ( You are welcome to view the First Light Facebook Page and read or share articles posted there, but clients of First Light Counseling and Psychological Services are not accepted as Fans of this Page. Having clients as Facebook Fans creates a greater likelihood of compromised client confidentiality. In addition, the American Psychological Association’s Ethics Code prohibits soliciting testimonials from clients, and the term “Fan” seems to come too close to an implied request for a public endorsement of the practice. Note that you should be able to subscribe to the page via RSS without becoming a Fan and without creating a visible, public link to the First Light Counseling and Psychological Services Facebook page. You are more than welcome to do this. A blog is posted on the First Light Counseling and Psychological Services website and tweets are sometimes posted on the First Light Counseling and Psychological Services Twitter account. Out of concern for your privacy, please consider more private ways to follow us on Twitter (such as using an RSS feed or a locked Twitter list), which would eliminate your having a public link to First Light content. You are welcome to use your own discretion in choosing whether to follow us. Note that Dr. Haworth will not follow you back, as he does not follow current or former clients on blogs or Twitter. If there are things from your online life that you wish to share with him, please bring them into your sessions where you both can view and explore them together during the therapy hour. Interacting *Please do not use SMS (mobile phone text messaging) or messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. These sites are not secure. Do not use Wall postings, @replies, or other

6   means of engaging with Dr. Haworth in public online if you have an already established client/therapist relationship. Engaging in this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.

Confidentiality: Discussions between a psychologist/therapist and a client

are confidential. No information will be released without the client’s written consent unless mandated or permitted by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in treatment facilities; sexual exploitation; AIDS/HIV and other communicable disease infection, and possible transmission; court orders; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist/psychologist has a duty to disclose, or where in the therapist/psychologist’s judgment, it is necessary to warn, notify, or disclose; sexual exploitation by a mental health professional or member of the clergy; fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist/psychologist; the filing of a complaint with a licensing board or other state or federal regulatory authority; to regulatory authorities in connection with their compliance or investigatory responsibilities; to employees or agents of First Light Counseling and Psychological Services for operational purposes; to a supervisor if the therapist is under supervision and for treatment consultations with other mental health professionals when deemed necessary by the therapist/psychologist. For further information review the full Notice of Privacy Practices posted on the practice website ( in conjunction with this Practice Policies and Client Information/Consent Document. A paper version of this Notice of Privacy Practices is available upon request. By signing this information and consent form below you acknowledge receipt of a copy of the Notice of Privacy Practices. If you have any questions regarding confidentiality, you should bring them to the attention of Dr. Haworth to discuss the matter further. By signing this information and consent form below, you are giving your consent to First Light Counseling and Psychological Services to share confidential information with all persons mandated or permitted by law, and you are also releasing and holding harmless First Light Counseling and Psychological Services and Dr. Haworth for any departure from your right of confidentiality that may result.

7   Electronic Records Disclosure: First Light Counseling and Psychological Services keeps and stores records for each client in a record-keeping system produced by TherapyNotes. This system is “cloud-based”, meaning the records are stored on servers which are connected to the Internet. Here are the ways in which the security of these records is maintained: • Dr. Haworth has entered into a HIPAA Business Associate Agreement with TherapyNotes on behalf of First Light Counseling and Psychological Services. Because of this agreement, TherapyNotes is obligated by federal law to protect these records from unauthorized use or disclosure. • The computers on which these records are stored are kept in secure data centers, where various physical security measures are used to maintain the protection of the computers from physical access by unauthorized persons. • TherapyNotes employs various technical security measures to maintain the protection of these records from unauthorized use or disclosure. • First Light Counseling and Psychological Services has it’s own security measures for protecting the devices that are used to access these records: o On computers, we employ firewalls, antivirus software, passwords, and disk encryption to protect the records from unauthorized access. o With mobile devices, we use passwords, remote tracking, and remote wipe capability to maintain the security of the devices and to prevent unauthorized persons from using it to access confidential records.

Duty to Warn: In the event that Dr. Haworth reasonably believes that you are

a danger, physically or emotionally, to yourself or another person, by signing this information and consent document, you specifically consent for Dr. Haworth to warn the person in danger and to contact any person in position to prevent harm to yourself or another person, in addition to medical and law enforcement personnel, and the following persons: Name Telephone Number ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

8   This information is to be provided at your request for use by said persons only to prevent harm to yourself or another person. This authorization shall expire upon the termination of your therapy with Dr. Haworth.

Contact Information: You consent for Dr. Haworth to communicate with you by mail, phone, and e-mail at the following addresses and phone numbers, and you agree to IMMEDIATELY advise the therapist in the event of any changes: Mailing Address: _______________________________________________________________________________________ Telephone Number(s): _______________________________________________________________________________________   E-mail Address: _______________________________________________________________________________________  

Couples/Family Therapy: If you participate in couples or family therapy with Dr. Haworth, you are agreeing to allow him to maintain a single case file for all participants in this couple or family pursuing treatment with him. Any release of these records, must be agreed to and signed by all participating adults.

Confidentiality when Treatment is with Child/Adolescent: Therapy is most

effective when a trusting relationship exists between the therapist/psychologist and the client. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children/adolescents to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. It is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. In order to allow a place where the adolescent feels comfortable talking about these difficult

9 subjects, some parents are more willing to exempt themselves from having to be made aware of these instances unless there is evidence of imminent danger. At the beginning of treatment, Dr. Haworth will discuss how this type of information should be shared/not shared with parents in your particular family. If he ever believes that your child is at serious risk of harming him/herself or another, he will inform you (the parent). In these cases, he always tries to let the child/adolescent know first that he will be sharing this information with the parent and why.

If you as a parent share custody of the child/adolescent for which you are pursuing treatment, it will be necessary for you to establish proof that his/her other custodial parent is in agreement with the therapy/assessment in writing – or to establish your right to pursue this treatment independent of their agreement by way of this being stated in the divorce decree or in a court order from the judge.

Legal Involvement: As Dr. Haworth’s main concern is to provide what will benefit the couple/family or minor, adult participants and/or parents of minors must agree that they will not attempt to use sessions to gain advantage in any legal proceeding. Participants also need to agree that neither of you will ask Dr. Haworth to testify in court, whether in person, or by affidavit. Should you end up in a legal proceeding, you are agreeing to instruct your respective attorney not to subpoena Dr. Haworth or to refer in any court filing to anything that he has said or done. Note that such agreement may not prevent a judge from requiring Dr. Haworth’s testimony, even though he will work to prevent such an event. If he is required to testify, he is ethically bound not to give his opinion about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, Dr. Haworth will provide information as needed (if appropriate releases are signed or a court order is provided), but he will not make any recommendation about the final decision. Furthermore, if he is required to appear as a witness, the party responsible for his participation agrees to reimburse Dr. Haworth at the rate of $350 per hour: including time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.



Consent to Treatment: I, voluntarily, agree to receive (or agree for my child to receive) Mental Health assessment, care, treatment, or services, and authorize Dr. Brian Haworth to provide such care, treatment, or services as considered necessary and advisable. I understand and agree that I will participate in the planning of my care (or my child’s care), treatment, or services, and that I may stop such care, treatment, or services that I receive (or my child receives) through Dr. Haworth at any time. By signing this Practice Policies and Client Information/Consent Document, I, the undersigned client (or parent), acknowledge that I have read, understood, and agreed to be bound by the terms, conditions, and information it contains. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

________________________________ Client/Parent

_________________________ Date

________________________________ Social Security Number for the person signing above

________________________________ Co-Client in case of Couples Therapy

_________________________ Date

________________________________ Social Security Number for the person signing above

as witnessed by: ________________________________ Brian D. Haworth, Psy.D., H.S.P. Licensed Clinical Psychologist First Light Counseling and Psychological Services

_________________________ Date

Practice policies and client information consent document (4 2014)  
Read more
Read more
Similar to
Popular now
Just for you