Confidentiality and privileged communication remain the rights of all clients of professional counselors according to law. However, there are limits to such communication some of which are mandated by state law. It is very important that you and those seeking counseling with you carefully read and understand the following limits of confidentiality.

Duty to Warn: Some courts have held that if an individual intends to take harmful, dangerous, or criminal action against another human being, or against himself or herself, it is the counselor's duty to warn appropriate individuals of such intentions. Those warned may include a variety of persons such as: The person or the family of the person who is likely to suffer the results of harmful behavior; the family of the client who intends to harm him/herself or someone else; associates, friends of those threatened, or making threats; and law enforcement and medical emergency officials.

Child Abuse: WA/OR. State law mandates the reporting of incidence of suspected incidence of child abuse including physical abuse, sexual abuse, unlawful sexual intercourse, neglect, emotional and psychological abuse. All actual or suspected acts of child abuse will need to be reported to the appropriate agencies.

"Dependent Adult" and Elderly Abuse: WA/OR law requires the incidence of "dependent adult" or elderly physical abuse reported to your counselor must also be reported to State authorities.

Family and Couple Therapy: Family members and couples may be seen at limes individually or conjointly. Information shared during these sessions or in related settings (e.g. telephone calls) is considered part of the overall family or couple therapy process and is not confidential from the other participating family members or partners. Ms. Ilona Pon will use her discretion in handling these matters. This is simply a "no secrets" policy. It is important that you understand this policy before treatment begins. It supports the belief that healthy relationships are built on openness and truth.

Case Evaluation: In order to ensure the best treatment possible for each client, Ms. Ilona Pon does consult with other professional counselor- the supervisor, regarding cases. This is traditional in both out-patient and in-patient counseling facilities and is referred to as "case conference" or "peer review." If you have any concerns regarding this practice, please notify your therapist.

Neglect of Outstanding Debt: In the event that a client fails to honor, after reasonable efforts to collect; his/her debt, Ms. Ilona Pon may place the account in the hands of an agency or attorney for collection or legal action. This will necessitate the release of pertinent demographic information as well as accounting information. NO THERAPEUTIC INFORMATION WILL BE RELEASED.

Maintenance of records: A written record of contact will be maintained in secure online database and some information such as notes during the session, in a locked filing cabinet in a locked office. Records are released only with your written permission.

Other than the exceptions noted above, information is released only with your voluntary written permission. I/We the undersigned, have read and fully understand the limits of my/our confidentiality. I/We further agree to abide by the policy set out above. I/We have had a chance to ask my/our counselor for additional clarification regarding the limits of confidentiality.

RELATIONSHIP

I understand that the effectiveness of psychotherapy depends on the efforts of the client as well as the practitioner, and I promise to make my best effort to comply with those procedures.  I understand that I am entering into a therapeutic relationship with a licensed professional.  I understand that this professional may recommend that I complete other forms of treatment; i.e.; psychological testing, psychiatric evaluation, or clinical homework.  I understand that I am fully responsible for the outcome of my treatment, and that results may vary based on adherence to such recommendations.  I further understand that IP.Counseling LLC (IPC) is making no guarantees about the outcome of treatment.

CANCELLATION POLICY

I understand that regular attendance will provide the maximum benefits but that I am free to discontinue treatment at any time.  If I decide to do so, I will notify the counselor at least two weeks in advance so that effective planning for my continued care can be implemented.  I will notify the counselor at least 24 hours in advance if I will be unable to attend any session.  If I fail to make such notification, I will be charged a $60.00 cancellation fee, and I will be solely responsible for these charges.  I understand that I can call IP.Counseling LLC 24 hours/7 days a week, and leave a message to cancel an appointment.  If I have three (or more) last minute cancellation or no-show appointments, my therapist may decide to discontinue our sessions, and refer me to a community mental health agency.

CONFIDENTIALITY POLICY

I further understand that conversations with the counselor will almost always be confidential.  I understand that a mental health professional, by law, must report actual or suspected child abuse or neglect or elder abuse or neglect to the appropriate authorities.  In addition, the counselor has the legal responsibility to protect anyone that I may threaten with violence, harmful or dangerous actions (including those to myself) and may break confidentiality of our communication if such a situation arises.  I understand that the mental health professional will make reasonable efforts to resolve these situations before breaking confidentiality.

PROFESSIONAL RECORDS

All counseling records are kept on a HIPAA-compliant server and/or under lock and key. IPC is the owner of all records. Records will not be released without your written permission except as mandated by law. You are entitled to receive a copy of your records at your written request, unless the counselor professionally believes seeing them could be emotionally harmful to you. Access requests for records must be in writing and must be acted on within 30 days. Access can be denied if it might harm the client. If you request your records, it is recommended that you and your counselor review them together to discuss their content. If you are denied access to your records you may appeal that decision to the State of Ohio, the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board. You can contact them: (614) 466-0912 or  cswmft.info@cswb.ohio.gov .

APPOINTMENTS FOR MINORS

At the first appointment for a minor, at least one biological parent must be present and bring a photo ID.  The counselor will need to match the signature on ID with signatures on paperwork. IPC is ethically bound to verify a minors' biological parents/guardian.  I understand that I am financially responsible for the cost of the counseling services. I must make payment arrangements with the office staff prior to future appointments being made. Failure to pay these bills may result in collection procedures (including court proceedings) being taken against me by IPC or a collection agency contracted by same to collect these bills.

COMPLAINTS

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the State of Ohio Counselor, Social Worker, and Marriage and Family Therapy Board at 614-466-5465. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. This office can assist you in attaining contact information.

FINANCIAL RESPONSIBILITES

I understand that I am financially responsible for the cost of the counseling services. I must make payment arrangements with the office staff prior to future appointments being made. Failure to pay these bills may result in collection procedures (including court proceedings) being taken against me by IPC or a collection agency contracted by same to collect these bills. There is a $20.00 fee for checks returned for insufficient funds. A flat fee of $30.00 will be charged for any forms that a client asks the clinician to complete, such as SSA, Disability papers, FMLA or leave of absence form.  Additional fees may be billed for extra services, including treatment or case summaries and reports, court related proceedings, and phone calls lasting more than 10 minutes (including coordination of care with other professionals and phone calls to clients directly). The counselor's fee is $90.00 for a regular counseling and life coaching session and $100 for EMDR session. Couple/marital/pre or post marital counseling and any dyadic relationships counseling costs 150$. If you or an organization on your behalf is requesting your medical records, we can do so with your written consent.  Medical records fee is $.50 for pages 1-50, and .25 for pages 51+.  It is the client's responsibility to pay for extra services.

If you ever experience something you identify as a life-threatening emergency, including your unwavering commitment to kill yourself and/or someone else, please call 911or Mobile Crisis Line: +1 216 623 6555.

ASSIGNMENT & RELEASE: I AM FINANCIALLY RESPONSIBLE FOR FULLY COVERING SERVICES. MY SIGNATURE BELOW INDICATES THAT I HAVE AGREED TO ALL THE ABOVE TERMS OF THIS CONSENT FOR TREATMENT/PROFESSIONAL SERVICES.

Benefits and Emotional Risks: The majority of individuals and couples/ families that obtain counseling or coaching services benefit from the process. The therapeutic process is generally quite useful, but some risks do exist. As counseling begins, please understand that some experience unwanted feelings, and that examining old issues may produce unhappiness, anger, guilt, or frustration. Important personal decisions are often an outcome of counseling. These are likely to produce new opportunities as well as unique challenges. Sometimes a decision that is positive for one couple member will be viewed as negative by another. Don't hesitate to discuss treatment goals, procedures or your impressions of the services that are being provided. Counseling and coaching are voluntary and you have the right to end services at any time.

Completing or Stopping Therapy: Periodically the counselor will assess how counseling or coaching work is going. If you are considering stopping the meetings, you may wish to let the counselor know in advance. If you allow yourselves 1-2 sessions for wrapping up, then the counselor and you can summarize the work you have done and forecast how you can maintain the progress you have made. This will help you to retain any new habits and changes you may have achieved.

The Privacy Policy & Procedures describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of the office health care operations. The Privacy Policy & Procedures also describes my rights and the responsibilities and duties of the office with respect to my protected health information. IP.Counseling LLC. Reserves the right to change the privacy practices that are described in the Privacy Policy & Procedures. If privacy practices change, I will be offered a copy of the revised Privacy Policy & Procedure at the time of my first visit after the revisions become effective. I may also obtain a revised Privacy Policy & Procedures by requesting that one be mailed to me.

Ilona Ponomariova, LPC does not make any court appearances.

I am a Licensed Clinical Counselor, who provides clinical counseling and coaching services to individuals, parents, couples, families and adolescents. This work takes the form of individual counseling, family and/or couples counseling and individual coaching. In my clinical role, I cannot assist my clients in divorce or custody litigation, and I disclose this fact to each client and client family who come to me for services. As a Licensed Clinical Counselor, I cannot disclose any marital therapy, couples counseling or family therapy information without the consent of all my clients.

Please do not ask me to write any reports for the court as I cannot do so. Do not ask me to testify in court, because this will destroy my professional relationship with my clients. I am not a custody evaluator and do not do Child and Family Investigation work or Parental Responsibility/Parenting Time evaluations. If the court has appointed a CFI or a PR/PT evaluator, those are the individuals that can make recommendations to the court. I cannot make recommendations to the court concerning parental responsibility or parental time issues. That would exceed my role as a therapist, and would adversely affect my ability to help families, parents and children. Furthermore, therapy is not the answer for legal disputes. Please do not request records for purpose of legal resolution.

Should Ms. Ilona Pon be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, the client agrees to reimburse Ms. Ilona Pon for any time spent for preparation, travel, or other time in which she has made herself available for such an appearance. Please ask for list of charges.

I/We the undersigned, have read and fully understand the above policies. I/We further agree to abide by the policies set out above. I/We have had a chance to ask my/our counselor for additional clarification regarding these policies.