Theresa Bonesteel, MA, LPC-I, LMFT-I
810 Dutch Square Blvd., Suite #207, Columbia, SC 29210
Phone: 803-465-5576/ Email: [email protected]
INFORMED CONSENT FOR TREATMENT AND DESCRIPTION OF SERVICES
What You Should Know About Your Counselor
As a Licensed Professional Counselor Intern (LPCI, #5731) and Licensed Marriage and Family
Therapist Intern (LMFTI #6004) in the state of South Carolina, I have a Masters of Arts in
Counseling from Columbia International University. I am a member of the American Mental
Health Counselors Association, American Association of Christian Counselors, Christian Mental
Health Network of SC. I am a certified facilitator for Prepare and Enrich, a pre-martial and
couples’ assessment, and trained in Trauma-Focus CBT. I enjoy working with children (ages 510), youth (ages 11-19), and adults of diverse ages and cultures in the following areas: Spiritual
growth, Anger Management, Anxiety, Depression, Grief/Loss, Sexual Abuse/ Trauma; Couples,
and Parent/Child relational issues, Parenting skills; and Pre- Marital counsel.
My style of counseling may include a variety of therapeutic interventions, depending on your
needs, personality, and learning style(s). Therapy can be hard and emotionally intense work, so
please know that your situation may get worse before getting better, and I cannot provide a
guarantee of treatment outcomes. This is a voluntary agreement, and you can choose to terminate
at any time without penalty.
Client Rights
1. To receive help, regardless of socioeconomic status, gender, race, religion, or physical
disability.
2. To know that therapy requires hard work, personal risk, discomfort, and pain. The client's
progress requires a consistent, concerted effort.
3. To understand the meaning of this Informed Consent as well as confidentiality in
counseling -- how data will be handled, who else will have access to privileged
communication, and in what circumstances confidentiality may be violated.
4. To review, revise, and have a collaborative role in the design of your treatment plan.
5. To a contractual arrangement, with fees and conditions clearly spelled out.
6. To refuse treatment to the extent permitted by law.
Agreement for Therapy
1. Responsibility and Scheduling: As an independent counselor, I take my own phone calls,
schedule appointments, see clients, collect fees, and function in complete autonomy from any
other counselor. All appointments can be scheduled directly with me by calling my confidential
phone number listed above. Please leave a message, and I will return your call within 24 hours.
It is generally best if a mutually agreeable time can be arranged on a weekly basis. However,
there will be special circumstances when more than one session per week is desirable. This will
be discussed with you, if appropriate.
2. Emergency Contact: If you need to reach me between our appointments, please call my
confidential phone number and leave a message. I will do my best to return your call within 24
hours. If you are unable to wait for my return call, please call 911, or go to the nearest
emergency room for assistance.
3. Sessions and Fees: My fee is $ 40.00 per 50-minute session. The 50-minute session includes
the time necessary to make your payment and schedule your next session. Extended time per
session can be discussed and agreed upon. Fees will be adjusted per any part of each 25 minutes
beyond the initial 50 minutes. (ex. 50 minutes + 25 minutes= $60). A sliding fee scale, based on
total annual income is available for unusual financial hardship.

Payments are due at the beginning of each session. You may pay by cash or check, and
your checks should be made payable to Theresa Bonesteel. Any checks returned as
“insufficient funds” will be charged an additional $30 fee to cover my bank fees. When
necessary, I am willing to offer counseling on a sliding scale with reduced rates so that
finances do not have to be a hindrance to getting help.
4. Insurance: As a Licensed Professional Counselor Intern in the state of South Carolina, I am
unable to accept insurance at this time.
5. Cancellation Policy: If cancellation is necessary, please provide at least 24 hours to cancel
your appointment. You will be charged a fee of $50.00 for any cancellation not made at least 24
hours in advance, and will be asked to pay that fee in addition to the session rate at the
subsequent session.
6. Confidentiality: South Carolina law requires our therapy relationship to be professional and
confidential. What you say and do in sessions with me will be kept in strict confidence. What is
revealed in this setting is protected by legal, professional, and ethical standards. However, as an
LPC-I, I am required by the South Carolina Licensing Board to be supervised by a Licensed
Professional Counselor Supervisor. I may discuss the nature of your case with my supervisor and
other LPC/I associates who may be sharing supervision time. However, at no time will your
identity be revealed unless I am required to do so. My supervisor and associate therapists are
legally bound to hold the information I share in strictest confidence. Otherwise, with a few
exceptions, your information is confidential and will not be released without your written
consent. These exceptions are as follows:
A) If I believe you are a threat to yourself in any way, I may have to seek hospitalization for you
or contact family members or others who can help protect you.
B) If I come to believe that you are threatening serious harm to another person, I am required to
try to protect the other person by notifying him/her and the police. I may also seek your
hospitalization. Note: This includes any situation in which an HIV+ person is engaging in sexual
contact with another person without first divulging their HIV status. This is a felony in South
Carolina. If you are HIV+, I will assist you in contacting the Health Department to implement
the partner notification process (your identity is not divulged to the party at risk).
C) In an emergency, where your life or health is in imminent danger, I may release information
to another professional to protect your life without your consent if I cannot get it.
D) If a child, an elderly person, or disabled person is being abused by neglect, assault, battery, or
sexual molestation – I am required to report this to the appropriate state agency.
E) If a judge orders me to release your records or to testify in court, I must comply.
F) Confidentiality regarding minors: Children under the age of 12 have little legal right to keep
information shared in therapy from their parents, if the parents ask. Between the ages of 12-18,
children begin to assume more legal rights. While most specific details will be treated as
confidential, parents or guardians do have the right to general information regarding therapy.
Regardless of your child's age, I will request that you, the parent or legal guardian of the minor
child, allow me the freedom to hold specific details of our conversations with your children in
confidence unless I determine the information is necessary for you to know, which then would
include harming self or another. This allows the therapy relationship to be a safe place for your
child.
G) Confidentiality regarding couple's counseling: I prefer to meet conjointly with couples at all
times. If I meet with either spouse for an individual session, please know that if you choose to
tell me something your spouse does not know, ethically, I cannot agree to keep it from him/her if
it would harm them. Hence, I will not participate in keeping secrets from your spouse. Referral
to another therapist may be necessary for individual work, and may require written consent for
communication between me and the other therapist, as agreed upon.
7. Relationships Outside of the Office: I hold to the standard that becoming "friends" with my
clients is not in your or my best interest. This policy includes not participating in social media
such as Facebook, Twitter, etc. I will not spend time with you socially or enter into a business
relationship or other relationship besides the therapeutic one. It is highly unethical and illegal for
me to enter into a sexual relationship with you. We will discuss at our first session your
preferred protocol if we accidentally meet outside of our scheduled sessions. You will never be
introduced to anyone I am with as a "client." If you see me at church, on the street, or in a public
location, I will only speak if you initiate the conversation. I want to do my best to honor your
privacy and not breach confidentiality.
8. Records: Your file containing your intake form, case notes on each session, any testing
results, records of our phone conversations, and any other written information you give me will
be kept under lock and key in my personal file. I prefer to submit a summary of treatment, and
you will be charged a processing fee of $20 for all requested copies of records. State and Federal
(HIPPA) laws dictate all record protection.
9. Legal Involvement: It is my policy that if counseling does not resolve marital difficulties and
you seek divorce, you agree not to request my testimony for either side in divorce or custody
cases. While I do not make court appearances, if I am subpoenaed for a court appearance, I must
have at least one week's prior notice to make other arrangements and reschedule other
appointments. My rate for a court appearance is $100/hour for two full eight-hour days ($1600),
even if the court time is only one hour. The full payment must be paid one week in advance of
the scheduled court date, and is non-refundable. Travelling expenses or additional preparation
charges will also be added.
10. Counselor's Vacation Schedule: As part of a healthy self-care routine, I will take four to six
weeks of vacation per year, not exceeding more than two weeks of vacation at any given time.
During my absence, you will have the name and phone number of another licensed professional
counselor who is willing to meet with you, if you so choose.
11.Termination of counseling occurs when: A) Treatment and goals are completed successfully
and counseling is no longer necessary, or B) the counselor and/or the client believe counseling
for any reason is no longer necessary or C) a client has not seen the counselor for a period of one
year.