Informed Consent Agreement- Adult Counseling

Informed Consent Agreement - Adult Oncology Counseling Services

Welcome to the Dempsey Centers for Quality Cancer Care. Our mission is to provide quality of life services to individuals and families impacted by cancer, including oncology counseling to help with adjustment to the emotional, physical, and social challenges presented by the cancer impact and/or loss of a loved one to cancer.

If you are reading this form, you have chosen to utilize our oncology counseling services.

Adult Oncology Counseling Services: We provide oncology counseling services by licensed mental health professionals (LCSWs and LMSW-CCs, all of whom are either board-certified in oncology [OSW-C] or working toward that designation). Our counseling services are designed to address many of the issues our clients are dealing with, and to provide our clients with an integrated experience for their mind, body, and spirit to enhance their adjustment to and coping across the continuum of the cancer impact from diagnosis through survivorship or bereavement, and to help enhance quality of life. Common concerns addressed in oncology counseling with both cancer patients and care partners/loved ones include:

• Stress related to cancer and/or treatment
• The impact of cancer on social and occupational roles and functioning (example: feelings of isolation, loss of a sense of purpose or identity, etc.)
• The impact of cancer on family and close loved ones
• The impact of cancer and treatment on body image/appearance
• The impact of cancer and treatment on sexual functioning/intimacy concerns
• The impact of cancer and treatment on cognitive functioning (ex: difficulty concentrating)
• The impact of cancer and treatment on energy level (ex: fatigue, insomnia)
• Fears of recurrence
• Sadness/depression/grief
• Anxiety/worries/fear
• Adjustment to the “new normal”/survivorship post-treatment
• Coping with advanced/metastatic illness
• Psycho-spiritual concerns (ex: concerns about mortality)
• Preparing for end of life
• Grief/bereavement

Your first visit will be an assessment session in which you and your counselor will determine your concerns and goals, and if both agree to proceed, a plan for further sessions will be developed. The goal of our counselors is to provide the most effective therapeutic experience available to you that will enhance your coping and quality of life.

Counseling sessions are typically 50 minutes in length and we provide up to 12 counseling sessions for those whose cancer impact is not advanced/metastatic, with the option to return for additional sessions if warranted. There are no session limits imposed for those who are living with advanced/metastatic disease. We provide 8 initial bereavement counseling sessions for those who have lost a loved one to cancer, with the option to return for 1-3 sessions as needed at significant anniversaries post- loss.

Risks and Benefits: Counseling is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. For example, during counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving. We cannot guarantee these benefits, of course. It is our desire, however, to work with you to attain your personal goals for counseling.

Communication regarding Concerns: In order for counseling to be beneficial, it is important that you are accurate, forthcoming and open to the modes of communication proposed by the counselor. If at any time you feel that you and your current counselor are not a good fit, please discuss this matter with your counselor or the Psychosocial Services Manager to determine if transferring to another counselor is right for you. If you and your counselor decide that other services would be more appropriate, we will assist you in finding a provider to meet your needs.

Confidentiality and Access to Records: Our policies about confidentiality, as well as other information about your privacy rights, are fully described in our Notice of Privacy Practices. That document has been made available to you, and you will be given a copy, upon request. As separately detailed in the Notice of Privacy Practices, there are situations when confidential PHI that includes counseling information may be disclosed to third parties by the Dempsey Centers, without a signed authorization by you. This includes, by way of example, when:
1. Necessary to help avert an imminent threat of serious harm to a client or others;
2. A report is mandated by law, if there is a reasonable suspicion of child abuse or abuse of an elder or incapacitated person;
3. Disclosure is required by a valid court order;

Please note that our counselors do obtain case consultation from time to time on an as-needed basis as reasonably necessary to support and enhance the delivery of the counseling services. In such an event every effort would be made to de-identify the information and to preserve confidentiality to the extent possible, but in all events within disclosures allowed by federal and state law.

While you may request to have access to your counseling records; it is within the discretion of the counselor, in accordance with applicable laws and standards, whether to provide a copy of the records to you in whole or in part, or in a summary written fashion.

Emergency Procedure; I understand that the Dempsey Center is not an emergency medical facility. In the event of a life-threatening or other health emergency, I should call 911. In the event of a mental health crisis, I am aware that I can call the Maine State Crisis Hotline at 1- 888-568-1112.
By signing this form, you acknowledge that you have been informed that Virtual Counseling Services may be available for you if you are receiving the services while in the State of Maine.Virtual Counseling Services (also commonly referred to as “distance counseling” “online counseling” or “telehealth” and referred to here as “Telehealth Services”) involve the use of two-way interactive audio, video or other electronic media technology by a health care provider to deliver clinical services at a distance for the purpose of diagnosis, treatment or education. Telehealth does not include the use of audio-only services. Telehealth also does not include the use of social media such as texts or e-mailing. Telehealth Services require the patient to use their own personal devices, such as smartphones, tablets, or computers, to connect with Dempsey Centers providers electronically, through Zoom or similar computer modes for audio and video conferencing.

My signature on this Informed Consent Agreement for Adult Oncology Counseling Services indicates that I:

• Have reviewed, understand, and consent to the policies and information above
• Have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me
• Consent to receive counseling services for myself
• I understand that I may stop such treatment or services at any time, and terminate the counselor/client relationship

Name of Client:(Required)
I understand that my typed name above will carry the same effect as my written signature(Required)