CHRISTIAN COUNSELING
SERVICES AGREEMENT
This agreement for Christian Counseling services between Dr. Nioka Smith Ministries, dba Dr. Nioka Smith Counseling and client(s) named below shall govern all professional relations between the parties. It is agreed that any disputes or modifications of agreement shall be negotiated directly between the parties; if negotiations are not satisfactory, then the parties agree to mediate any differences with a mutually acceptable third-party mediator, considering first either the President or Director of the practice.
A. THE CHRISTIAN COUNSELOR
is Dr. Nioka Smith. She is a Licensed Clinical Christian Counselor, not a state licensed therapist. Additionally, within her Counseling License, she holds ADVANCED certification in Marriage and Family Therapy, Sexual Abuse Therapy and Child Abuse Recovery.
B. CHRISTIAN COUNSELING AT
Dr. Nioka Smith Counseling is confidential, supervised counseling by one trained and experienced in the pastoral and counseling ministry. Christian
counseling usually ranges from 6 to 12 sessions overall with an evaluation at the end of this program of counseling after which, counseling may be terminated or
referral for further treatment may be made at this time, whichever is in the client’s best interest.
C. FEES AND INSURANCEPOLICY
Full payment shall be made prior to the start of each session by the client. Clients understand that we do not accept insurance. Clients are fully responsible for the payment of all fees.
D. CANCELLATION POLICY
There will be no refunds. We ask that all clients maintain responsible relations regarding appointment times. If clients need to reschedule, clients must do so at least one (1) full day before the scheduled appointment. All no shows and rescheduled appointments outside of this timeframe will be automatically charged a $50 cancellation fee.
E. CONFIDENTIALITY POLICY
All therapeutic communications, records, and contacts with professional and support staff will be held in strict confidence. Information may be released, in accordance with the state law, only when (1) the client signs a written release of any information indicating informed consent to such released; (2) the client expresses serious intent to harm himself/herself or someone else; (3) there is evidence or reasonable suspicion of abuse a minor child, elderly person (sixty-five years or older), or dependent adult; or (4) a subpoena or other court order is received directing the disclosure or information. It is our policy to assert either (a) privileged communication in the event of #4 or (b) the right to consult with clients, if possible, barring an emergency, before mandated disclosure in the event of #2 or #3. Although we cannot guarantee it,
we will endeavor to apprise clients of all mandated disclosures. Clients with any concerns or questions about this policy agree to raise them with their counselor at the earliest possible time to resolve them in the client’s best interest.
F. WORK AGREEMENT
It is agreed that the client shall make a good-faith effort at personal growth and engage in the counseling process as an important priority at this time in his
or her life. Client gain is most important in Christian counseling. Suspension, termination, or referral shall be discussed between counselor and client for a
pattern of behavior that reveals disinterest or lack of commitment to counseling or for any unresolved conflict or impasse between counselor and client.
Our sessions will require that you trust 4 entities:
Trust Me…. Trust the Holy Spirit…. Trust You…. Trust the Process.
Remember this process will require you to do the work yourself. We cannot do the work for you. The amount of sessions that are required to complete counseling will
vary, depending on the depth of your situation and the amount of effort you give. Dr. Nioka Smith and client further agree that the following needs or problem issues will be addressed in both counseling sessions and in client homework, with future revisions possible as need rises: _________________________________________________________________
G. SERVICE FEES
Individual Counseling (IN PERSON) 1hr/$105
Individual PHONE Counseling 1hr/$105
Couple’s Counseling 1.5hr/$150
Family Counseling (3-5 people) 2hr/$220
Extended Counseling Session 2hr/$200
Group Counseling (5 or more people) 2hr/$250+
Mini Counseling Session (Existing Clients Only) 30mins/$60
Consultation-In Person 20mins/$50
Consultation-Phone Free
Business Consultation 1hr/$200
H. DOCUMENT PREPARATION
Should a client request counseling notes or correspondence to be sent to a third party, it is understood that the following fees shall apply. Arkansas Code Title 16.
Practice, Procedure, and Courts § 16-46-106. allows providers to charge a retrieval fee for medical records sent to entities such as law offices, disability claims, and other organizations. While the medical records requests will be fulfilled, there is an allowable seven (7) business days to fulfill the request, per Arkansas statute. Please see below for retrieval fees.
Requesting
Party Retrieval Fee Per Page Fee
Patient/Client* $25.00 $0.75
Social
Security Disability $25.00 $0.00
Workers
Compensation $25.00 $0.75
Other
Organizations $25.00 $0.75
I. AUDIO & VIDEO RECORDING
Because confidentiality is an important element of the Counseling process, no recording may take place by the Christian Counselor without prior written consent of the client. Likewise, the client may not record any sessions via cell phone, camcorder, or any other audio recorder or video recorder without prior consent of the Christian Counselor.