Jenny Buysse Counseling & Career Consulting, PLLC

CREATING POSITIVE SUPPORTIVE CHANGE THROUGH COUNSELING, EMPOWERING, AND INSPIRING CLIENTS!,

PRIVACY PRACTICES POLICY AND PROFESSIONAL DISCLOSURE

You, or a member of your family, are about to become involved in counseling with a trained and licensed/certified
counselor. We wish to take this opportunity to welcome you and also to state some basic principles we believe essential
in establishing a good counseling relationship between us. Please read through this information, asking questions as
needed.

1. INITIAL INTERVIEW: Your first visit is considered a diagnostic or evaluation interview. At the time of this
appointment, the following decisions will be made with you:
a) Type of therapy needed (individual, group, medication referral, etc.)
b) Frequency of therapy sessions (weekly, biweekly, etc.)
c) Goals of therapy (what you hope to gain from this process.)
d) Referral (if counseling services are out of counselors scope of practice.)

2. PROCESS: The expectation of counseling and career counseling is to develop a working relationship between you and
the counselor. Within this working relationship, it is our goal to provide counseling that:
a) empowers clients to learn about themselves,
b) coping strategies, and
a) utilize tools and resources make confident, educated, and informed personal and career decisions.
The process allows for deeper understanding of yourself and resources in establishing a counseling plan and next
steps. You should be aware that change (positive or negative) can produce disruption and turmoil in ones life.

3. GOAL: Our goal is to counsel, encourage, and motivate individuals in their personal and career development.
Services may include:
a) counseling, career counseling, assessments, resource information, and
b) coaching and employment skills to assist you in addressing your needs.
In this dual relationship, it is expected that there will be collaboration with both the counselor and yourself. You may
be given homework to complete toward your counseling goals.

4. CREDENTIALS: Counselor is Licensed Professional Counselors (L.P.C.) from the State of Michigan. In addition, the
counselor holds other certifications including:
a) National Certified Counselor (N.C.C.) though the National Board for Certified Counselors,
b) Global Career Development Facilitator (G.C.D.F.), and
c) Board Certified Coach (B.C.C) both through the Center of Credentialing & Education.

5. APPOINTMENTS: Each appointment is approximately 45-50 minutes. At the end of each appointment you can
discuss future appointments with your therapist.

6. CANCELLATIONS: If you find that you need to cancel an appointment, please give as much notice as possible so
that we can schedule people that are on our waiting list. You will be personally charged for your appointment if
not canceled at least 24 hours in advance other than for emergency reasons.

7. TERMINATION: You have the right to terminate the counseling relationship at anytime. Out of respect for the
counseling process, please inform your counselor of such decision, so the counselor can further assist you in
your direction.

1611 W. Centre Ave, Suite 200| Portage, MI 49024| 269.224.2775

Website: www.jennybcounseling.com| Email: jenny@jennybcounseling.com
 Jenny Buysse Counseling & Career Consulting, PLLC
CREATING POSITIVE SUPPORTIVE CHANGE THROUGH COUNSELING, EMPOWERING, AND INSPIRING CLIENTS!,

8. PAYMENTS: We would greatly appreciate payment in full for each office visit when you come for your
appointment. If you do not pay in full at the time of service. Charges for services in addition to therapy may be
levied (i.e., involvement in client litigation, document preparation, etc.). These fees will be negotiated
individually with your counselor. We accept credit cards, cash, and check. Please make checks out to Jenny
Buysse Counseling PLLC.

9. INSURANCE: The counseling practice participates with different insurance companies. Please contact the office
to check if we participate with your health insurance provider. For the insurance companies we participate with,
co-payments, if applicable, are due from the patient at the time of the insurance. The patient is also responsible
for deductible, coinsurance, and non-coverage or non-authorized services. If the counseling practice does not
participate with your insurance or you are interested in using out of network or private payment, I am eager to
offer counseling services to you. The ultimate goal is providing counseling services to you. We can discuss
alternative payment arrangements for out of network and private payment. The counseling office can assist you
in contacting your insurances for both in and out of network, giving you receipts to submit, and follow up
contacts. For your convenience, we accept VISA, Mastercard, checks, and cash. Payments for services received
through Jenny Buysse Counseling & Career Consulting are expected at the time of service. All payment and fees
incurred during counseling services are ultimately your responsibility. Late charges of 2% per month will be
added to balances existing for more than 30 days.

10. CONFIDENTIALITY: All information regarding the specific nature of your counseling is maintained at Jenny
Buysse Counseling & Career Consulting, PLLC and is considered confidential within the office unless specified by
you in writing. However, you should understand the limits of confidentiality. Confidentiality is expected except
when the counselor believes a clients behavior is dangerous to self or others, in suspected child abuse or elderly
abuse, and in compliance with legal requirements. Counselor are bound to report to appropriate authorities in
such cases. The counselor reserves the right to use specialty consultation with other counselors as deemed
necessary. If you choose to have the office file your insurance claims, treatment information, including
diagnosis, treatment plans, dates of services (and potentially other information) will be released to your
insurance company. Please be assured that your identity will be kept confidential, where all possible.

11. RECORDS OF MINORS: Parents and legal guardians of minors may not be denied access to their childs records.

If more than one adult patient, each person should check and initial boxes.

Yes No I acknowledge that I have read and understand all of the foregoing statements and that
my signature below indicates that I agree to abide by all of the above conditions.
Yes No I have received a copy of the Privacy Practices Policy and Professional Disclosure Form.
Yes No I consent to the exchange of treatment information between Jenny Buysse Counseling &
Career Consulting and my primary care physician.

Patient(s)Physicians Name/Office and Phone Number

Signed: Date:

Signed: Date:

1611 W. Centre Ave, Suite 200| Portage, MI 49024| 269.224.2775

Website: www.jennybcounseling.com| Email: jenny@jennybcounseling.com
 Jenny Buysse Counseling & Career Consulting, PLLC
CREATING POSITIVE SUPPORTIVE CHANGE THROUGH COUNSELING, EMPOWERING, AND INSPIRING CLIENTS!,

CLIENTS COPY KEEP THIS FORM FOR YOUR RECORDS

PRIVACY PRACTICES POLICY AND PROFESSIONAL DISCLOSURE

You, or a member of your family, are about to become involved in counseling with a trained and licensed/certified
counselor. We wish to take this opportunity to welcome you and also to state some basic principles we believe essential
in establishing a good counseling relationship between us. Please read through this information, asking questions as
needed.

12. INITIAL INTERVIEW: Your first visit is considered a diagnostic or evaluation interview. At the time of this
appointment, the following decisions will be made with you:
e) Type of therapy needed (individual, group, medication referral, etc.)
f) Frequency of therapy sessions (weekly, biweekly, etc.)
g) Goals of therapy (what you hope to gain from this process.)
h) Referral (if counseling services are out of counselors scope of practice.)

13. PROCESS: The expectation of counseling and career counseling is to develop a working relationship between you and
the counselor. Within this working relationship, it is our goal to provide counseling that:
c) empowers clients to learn about themselves,
d) coping strategies, and
b) utilize tools and resources make confident, educated, and informed personal and career decisions.
The process allows for deeper understanding of yourself and resources in establishing a counseling plan and next
steps. You should be aware that change (positive or negative) can produce disruption and turmoil in ones life.

14. GOAL: Our goal is to counsel, encourage, and motivate individuals in their personal and career development.
Services may include:
c) counseling, career counseling, assessments, resource information, and
d) coaching and employment skills to assist you in addressing your needs.
In this dual relationship, it is expected that there will be collaboration with both the counselor and yourself. You may
be given homework to complete toward your counseling goals.

15. CREDENTIALS: Counselor is Licensed Professional Counselors (L.P.C.) from the State of Michigan. In addition, the
counselor holds other certifications including:
d) National Certified Counselor (N.C.C.) though the National Board for Certified Counselors,
e) Global Career Development Facilitator (G.C.D.F.), and
f) Board Certified Coach (B.C.C) both through the Center of Credentialing & Education.

16. APPOINTMENTS: Each appointment is approximately 45-50 minutes. At the end of each appointment you can
discuss future appointments with your therapist.

17. CANCELLATIONS: If you find that you need to cancel an appointment, please give as much notice as possible so
that we can schedule people that are on our waiting list. You will be personally charged for your appointment if
not canceled at least 24 hours in advance other than for emergency reasons.

18. TERMINATION: You have the right to terminate the counseling relationship at anytime. Out of respect for the
counseling process, please inform your counselor of such decision, so the counselor can further assist you in
your direction.

1611 W. Centre Ave, Suite 200| Portage, MI 49024| 269.224.2775

Website: www.jennybcounseling.com| Email: jenny@jennybcounseling.com
 Jenny Buysse Counseling & Career Consulting, PLLC
CREATING POSITIVE SUPPORTIVE CHANGE THROUGH COUNSELING, EMPOWERING, AND INSPIRING CLIENTS!,

19. PAYMENTS: We would greatly appreciate payment in full for each office visit when you come for your
appointment. If you do not pay in full at the time of service. Charges for services in addition to therapy may be
levied (i.e., involvement in client litigation, document preparation, etc.). These fees will be negotiated
individually with your counselor. We accept credit cards, cash, and check. Please make checks out to Jenny
Buysse Counseling PLLC.

20. INSURANCE: The counseling practice participates with different insurance companies. Please contact the office
to check if we participate with your health insurance provider. For the insurance companies we participate with,
co-payments, if applicable, are due from the patient at the time of the insurance. The patient is also responsible
for deductible, coinsurance, and non-coverage or non-authorized services. If the counseling practice does not
participate with your insurance or you are interested in using out of network or private payment, I am eager to
offer counseling services to you. The ultimate goal is providing counseling services to you. We can discuss
alternative payment arrangements for out of network and private payment. The counseling office can assist you
in contacting your insurances for both in and out of network, giving you receipts to submit, and follow up
contacts. For your convenience, we accept VISA, Mastercard, checks, and cash. Payments for services received
through Jenny Buysse Counseling & Career Consulting are expected at the time of service. All payment and fees
incurred during counseling services are ultimately your responsibility. Late charges of 2% per month will be
added to balances existing for more than 30 days.

21. CONFIDENTIALITY: All information regarding the specific nature of your counseling is maintained at Jenny
Buysse Counseling & Career Consulting, PLLC and is considered confidential within the office unless specified by
you in writing. However, you should understand the limits of confidentiality. Confidentiality is expected except
when the counselor believes a clients behavior is dangerous to self or others, in suspected child abuse or elderly
abuse, and in compliance with legal requirements. Counselor are bound to report to appropriate authorities in
such cases. The counselor reserves the right to use specialty consultation with other counselors as deemed
necessary. If you choose to have the office file your insurance claims, treatment information, including
diagnosis, treatment plans, dates of services (and potentially other information) will be released to your
insurance company. Please be assured that your identity will be kept confidential, where all possible.

22. RECORDS OF MINORS: Parents and legal guardians of minors may not be denied access to their childs records.

If more than one adult patient, each person should check and initial boxes.

Yes No I acknowledge that I have read and understand all of the foregoing statements and that
my signature below indicates that I agree to abide by all of the above conditions.
Yes No I have received a copy of the Privacy Practices Policy and Professional Disclosure Form.
Yes No I consent to the exchange of treatment information between Jenny Buysse Counseling &
Career Consulting and my primary care physician.

Patient(s)Physicians Name/Office and Phone Number

Signed: Date:

Signed: Date:
CLIENTS COPY KEEP THIS FORM FOR YOUR RECORDS

1611 W. Centre Ave, Suite 200| Portage, MI 49024| 269.224.2775

Website: www.jennybcounseling.com| Email: jenny@jennybcounseling.com