Disclosure Statement

Dear Lifecore Counseling & Behavioral Health Services Clients:

Welcome to Lifecore Counseling & Behavioral Health. Our goal is to assist you with any work or personal difficulties you may be experiencing. In many instances, our consultation and referral services may also be offered to your spouse, partner, and/or eligible dependents. Please review the following information. If you have any questions or concerns, please be sure to discuss them with your counselor. 

Mental Health Counseling

Our clinical staff consists of masters- and doctoral- level licensed mental health professionals who will help you find solutions to best fit your individual needs. During your initial session, counselors will provide you with a personal disclosure statement, as well as background information about their credentials, education and training, years of experience in the field, methods, and treatment modalities.

Scope of Services

The number of sessions available is determined by you and your counselor’s recommendations regarding your specific needs. If you and your counselor determine that your needs reach beyond the scope of this program, or if you exhaust the number of sessions available, your counselor will work with you to make a referral. In the referral process your counselor will make every effort to match your needs to community resources to ensure an effective continuum of care.

This program provides assessment, referral, and intervention services; however, highly specialized critical care, long-term mental health, and complicated relationship issues can result in a referral in the first few sessions. The following are examples of complex cases that receive direct referrals: 

• Hospitalization due to active suicidal and/or homicidal intention
• Psychological testing
• Any case with imminent court involvement
• Assessments for medical procedures such as bariatric or transplant surgery
• Court-ordered issues including, but not limited to:
  • Anger Management courses
  • Divorce Court proceedings
  • Drug treatment
    
    

Problems Covered Include:

• Individual, Relationship, and Family Issues
• Parental Issues
• Grief, Depression, and Anxiety
• Life Stress
• Academic Stress
• Addiction
• Child/Adolescent Behavioral Issues
• Financial Resources and Referrals
• Elder and Child Care Issues
• Resources and referrals for community counselors, groups, and other supportive services

Office Hours:

Monday-Friday: 9 a.m. – 5 p.m. Appointment hours vary. Every attempt will be made to provide an appointment that will meet your needs. Weekend/holiday hours are in accordance with Marvelly & Associates.

Emergency Situations

The clinical team rotates being on-call for emergency situations. Although rare, there may be a time when, during your session, your counselor may need to step out of the room to take an emergency call. When your counselor is on call, they will advise you at the start of the session.

Contact with Marvelly & Associates

Our main phone number is (832) 774-7444. Routine counseling or requests to speak with your counselor are handled during normal office hours described above. If for some reason, we need to contact you between appointments, we ask that you provide a phone number where we can leave a confidential message for you. If this is not possible, it will then be your responsibility to call prior to each appointment to confirm the date and time.

“No-Show” and Cancellation Policy

Every scheduled session is reserved exclusively for you and represents an agreement on your part to take an active role in the counseling service provided by this program. Therefore, you agree to the following:

• Counseling sessions are generally 45 minutes in length.
• If you are unable to keep and appointment, we request that you notify us at least 24 hours in advance.
• In the event of you missing an appointment, it is your responsibility to reschedule with us.
• If 30 days pass and we do not hear from you, we will assume you are no longer interested in counseling and your record will be closed.
• You are welcome to call us at any time to reinitiate services. 

Policy Regarding Children

A parent or legal guardian must accompany all children under the age of 16 to all appointments scheduled with Marvelly & Associates. The parent or legal guardian must remain on the premise throughout the session. No child care services are provided. Appropriate supervision of children is required at all times. In the event that a parent and child are both scheduled to be seen individually, another adult must accompany the child to provide supervision while the parent is in session. Our policy on disclosure of information to a parent not attending the session is based upon documented legal status. Both parents have a right to information regarding their child unless the courts have determined otherwise. In the event of step-parenting relationships, we may require documentation that you are authorized to consent for the treatment of the child.

Clients of Marvelly & Associates have the right to:

• Be treated with respect.
• Have written information before consenting to evaluation and treatment about our counseling services, policies, and procedures.
• Be informed of potential risks and benefits of counseling.
• Ask any questions about the counseling process and therapeutic techniques that your counselor uses or plans to use.
• Ask about the clinician’s qualifications (education, training, and/or experience).
• Refuse to answer any questions.
• Refuse the administration of any evaluation procedure or intervention.
• Discuss your counseling with anyone you choose, including another clinician.
• Request another clinician if uncomfortable or dissatisfied, counseling is voluntary and you have the right to choose a clinician that suits your needs. Should you wish to see a different clinician, we will provide a referral to an alternate clinician with Marvelly & Associates or within the community. Referrals made to outside providers may or may not be covered under your health insurance.
• File a complaint with the clinician’s Supervisor, Program Administrator, the Licensing Board, or other appropriate government agencies about problematic, unethical, or illegal behavior by your clinician.

 

If you have any questions, or if you wish to file a complaint, please contact one of the following:

Duken Marvelly, LCSW-LCDC

Psychotherapist

Marvelly & Associates

(832) 774-7444

 

Texas State Board of Examiners of Professional Counselors

1100 West 49^th Street

Austin, TX 78756-3183

(512) 834- 6658

Texas State Board of Social Worker Examiners

PO. Box 141369

Austin, Texas 78714-1369

(512) 719-3521

Effects of Counseling

Most clients can expect to benefit from our services, making positive changes in their thoughts, feelings, and/or behaviors. Some however, may not find counseling beneficial, and a very few may have a negative counseling experience. Even the most successful counseling and therapy may at times be uncomfortable as you deal with emotionally difficult issues. As you make personal changes, you may also see changes occur in your relationships with others. If you have any questions about the possible effects of counseling or any services you are receiving, you are encouraged to discuss them with your clinician.

Confidentiality

All aspects of your participation in counseling at Marvelly & Associates, including the scheduling of appointments, contents of counseling sessions, all contents of counseling records, and outcomes of counseling are confidential by state law. A confidential record of the counseling services provided to you will be maintained as required by state law. Only the specific individual may have access to his or her file. Your counseling record consists of both paper file and electronic database components. All parts of your record are highly secured physically and/or electronically, and are protected by the same confidentiality and privacy laws.

Marvelly & Associates operate as a single entity, which means that clinicians within may share your information when consulting with each other to provide you the most effective services. Only professional clinicians may access clinical progress notes, test data, or other clinical information in your file. Support staff may have access only to contact and demographic information and diagnostic codes for the purpose of statistical tracking and reports. No record of counseling is made on an academic transcript or job placement file. Ownership of all physical records is retained by Marvelly & Associates, which is responsible for establishing policies regarding retention of counseling records. No information may be released without your written permission, with the following exceptions:

Exceptions to Confidentiality

Marvelly & Associates may use or disclose personal health information (PHI) without your consent or authorization in the following circumstances:

• Texas Law requires that counselors who learn of or have strong suspicions of child abuse or neglect report this information to Child Protective Services or to law enforcement personnel. This pertains specifically to knowledge of: child abuse or neglect of a client who is under 18 years of age, any child under 18 years of age suspected of being at risk of abuse or neglect, or counseling of child abuse or neglect according to the criteria mentioned above. All reports of such incidents or suspicions will be reported by our clinicians and are not protected by confidentiality.
• Texas Law requires abuse or neglect of elderly persons or persons with disabilities to be reported to the proper authorities.
• If a clinician assesses that you pose an imminent danger to yourself or others, the clinician may do what is necessary to protect life within the limits of the law.
• A court-ordered subpoena can require the release of records kept or require a clinician give testimony at a court hearing.
• Texas Law requires a clinician to report client abuse or sexual exploitation by a previous therapist to the appropriate county district attorney and licensing board. Client anonymity will be preserved if requested.

PLEASE SEE BELOW FOR SIGNATURES AND REVIEW OF THE ABOVE INFORMATION

I have read and fully understand the preceding description and conditions of Marvelly & Associates’ procedures and policies. I agree to permit my clinician to discuss the nature of my problems with other Counseling Service staff. I understand this Disclosure Statement and I consent to clinical counseling. Additionally, I consent to the following:

• After a missed appointment (either due to a cancellation or a “no-show”), I have 30 days to contact Marvelly & Associates for a follow-up appointment. After a month, I understand that this office will assume that I am no longer in need of services, and my case will then be closed.
• It is my responsibility to notify Marvelly & Associates if my contact information changes.
• Should my counselor consider me a threat to myself or others at any time in the course of assessment or treatment and should I need emergency care including dispatching an ambulance and/or hospitalization, I will be financially responsible for all interventions performed on my behalf.
• You have my permission to contact me by telephone, and if needed leave a message, at the following number: _________________________________________.
• I understand the above information and have received my own copy of this form for my review.

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Client Signature                                                                                                                       Date

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Client Name (Print)

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Clinician Signature                                                                                                                  Date