Site Content

Informed Consent  

Therapist’s Name: Dr. Charles Greene, DBH, LPC, ACS, BC-TMH 

Office Address: 323 Pine Ave Suite 113, Albany, GA 31701 

P: (229) 355-3065 

F: (229) 518-1602 

Email: drgreene@metacognitive-strategies.com

Secure Virtual Session option 1: https://doxy.me/drcharlesgreenelpc

Secure Virtual Session Option 2:  https://sessions.psychologytoday.com/Dr-charles-greene 

Welcome! To begin your counseling journey, this form will provide you with information on your clinician's credentials, the process of counseling, confidentiality, emergencies, and other details about your treatment. At any time during your treatment, please feel free to ask any clarifying questions.

Credentials

Licenses: 

Licensed Professional Counselor in the state of Georgia, LPC010556 

Licensed Mental Health Counselor Out-of-State Telemental health, TPMC150

Link to verify your clinician's license:

Georgia - http://verify.sos.ga.gov/verification/

Florida - https://appsmqa.doh.state.fl.us/MQASearchServices/Telemental health/LicenseVerification?LicInd=171&ProCde=9646

Certifications: 

Approved Clinical Supervisor (ACS), 3443

Board Certified-TeleMental Health Provider (BC-TMH), 2079

Counseling experience: 

8 years 

My schooling:

• Doctor of Behavioral Health (DBH), Arizona State University

• Master of Arts in Counseling, Clinical Mental Health, Adams State University

• Bachelor of Arts in Sociology, American Military University

Theoretical orientation

 My practice embraces an all-encompassing approach toward making changes in multiple areas of your life based on Albert Ellis’s theory of Rational Emotive Behavior Therapy (REBT). REBT is an action-directed therapy in which emotional and behavioral problems are addressed through exploration of your beliefs. Ellis believed that if you change your thinking you can change your life.  

Benefits and risks of psychotherapy 

The psychotherapy that we will be doing is intended to address the specific issue(s) that you and I decide on addressing. Psychotherapy may also bring deeper personal insight and awareness; solutions to, or better ways of understanding and coping with problems; improved relationships; significant reductions in feelings of distress; and greater insight into personal goals and values. 

You should know, however, that psychotherapy usually requires that you be willing to examine and discuss difficult topics or times in your life, to experience stronger than usual emotions, and to try out new and different behaviors. The therapy may feel challenging and difficult at times. Uncomfortable feelings and experiences may be addressed (in that you may feel anger, sadness, guilt, grief, loss, frustration, etc.) as well as physical discomforts or pains (nausea, aches, pains). During treatment, you may feel worse before you start to feel better. And I simply may not be able to help you, or, in rare cases, make you feel worse than when we started. However, you ultimately get to decide what we discuss and with whom you will work. If you feel uncomfortable or not ready to discuss an issue at any point, this is completely okay. 

In your session, we’ll almost certainly be using one or more counseling modalities or approaches, depending on your issue and other factors. There are other different types of therapy you might want to pursue instead. For example, you might simply need a counselor to help you come to a decision in your life, and not someone to address the feelings you have around the situation. If you decide to continue, we’ll look at the issue you want to address, and decide if it is something we can agree on treating, and ways to measure success. And of course, after this discussion, you may realize that not doing anything is the right thing for you at this time. 

Expectations of the client

The client agrees to– 

1. Avoid using mind altering substances prior to session

2. Dress appropriately during face-to-face or web-based sessions 

3. Be located in an area that is safe and provides privacy (Telemental health)

4. Be located in an area that is appropriate for a web-based session, such as a home office (Telemental health)

5. Not have anyone else in the room unless you first discuss it with your clinician (Telemental health)

6. Not conduct other activities while in session, such as driving (Telemental health)

7. Not bring any weapons of any kind to session

8. Not record sessions without first obtaining the provider’s approval

9. Be located within the states of Georgia or Florida in which the clinician is licensed to practice (Telemental health)

Confidentiality and Records 

During our sessions, I may be taking written notes as this helps me remember what we accomplished or still need to do; and can help remind you too, because one of the common effects of modern therapy is forgetting what one’s issue used to be (the ‘apex effect’). All of your PHI (Protected Health Information) is kept for a minimum of five years in a locked file cabinet. 

It is your clinician's personal, professional, and legal obligation to keep all of your protected health information (PHI) confidential, with some exceptions. This document provides detailed information on how private information about your health care is protected and under what circumstances it may be shared. 

Your communications with me will become part of a clinical record of treatment. I will keep everything we discuss completely confidential, with the following exceptions: 

a) If I believe that you or another person is a clear risk of imminent harm 

b) If a child, elderly person(s) or a disabled person(s) is or may be at risk of abuse, neglect or are in need of protection

c) For the purpose of complying with a legal order such as a subpoena, or if the disclosure is otherwise required or authorized by law. 

d) I may also disclose information for the purpose of a professional consultation, or for a professional presentation or paper, in which case your identity will remain confidential. 

e) I may also be sharing anonymous data (length of time, effectiveness, unusual problems) from our sessions to help improve the quality of the processes we are using. 

Other than the exceptions listed above, I, Dr. Charles Greene, DBH, LPC, ACS, BC-TMH will be the only person viewing your information. 

Email:

Email is not always secure; therefore, I do not use email to send or receive client information. 

Text/SMS:

All chat correspondences will be done through the free to use Signal Private Messenger app, which uses an end to end encryption protocol to prevent messages from being stolen by hackers, third party applications and government agencies. 

Video Conferencing:

All video conferencing correspondence will be done through the free to use Doxy.me platform and/or Psychology Today Sessions, which are HIPAA compliant and provides a Business Associate Agreement. 

Risks / Client’s Responsibilities / Client’s Protection

When using technology for communication, there is a risk that it may be forwarded, intercepted, circulated, stored, or even changed, and the security of the devices used may be compromised. Although I make reasonable efforts to protect the privacy and security of all electronic communication with you, it is not possible to completely secure the information. If you use any other methods of electronic communication with me, other than the means recommended by me, there is a reasonable chance that a third party may be able to intercept that communication. 

With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may have access to any technology, devices, or applications that you use. I encourage you to only communicate through a computer, or any other device that you know is safe. You are responsible for reviewing the privacy settings and agreement forms of any applications or technology you use. Please contact your clinician with any questions that you may have on privacy measures.

Contact information

When you need to contact your clinician for any reason, these are the most effective ways to get in touch in a reasonable amount of time is to leave a message using your client portal.

Social media/everyday life

Please refrain from making contact with your clinician using any social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I am not prepared to watch them closely for important messages from clients. 

The world can sometimes be a small place! If by chance you and I happen to run into each other outside of this platform, I will not initiate contact or indicate that I know you in anyway. If you decided to acknowledge me then I will of course respond back in kind. If you happen to be with someone you do not wish to know the nature of our relationship, please know that I will not disclose how we know each other; I will keep the interaction brief for your privacy. 

Boundaries

The American Counseling Association (ACA) prohibits certain types of relationships between therapist and client. Section A.5 of the ACAs code of ethics states that sexual and/or romantic relationships with a current or former client are prohibited. Therapists are also prohibited from engaging in counseling relationships with friends, family members and past sexual and/or romantic relationship partners, regardless of how long ago the relationship took place. 

Response Time

I usually check my messages several times daily but please be aware that there may be times when I am unable to receive or respond to messages as quickly as you would like. I may not be able to respond to your messages immediately, but you can expect a response within 24 hours on weekdays, and 72 hours on weekends. 

Emergency Contact 

I provide only non-emergency therapeutic services by scheduled appointments. If you need additional or more intensive services, I may refer you to another organization to receive extended services. All other concerns should be addressed in your regular therapy session. If you are ever experiencing an emergency, including a mental health crisis, please:

Georgia & Florida - call 911

Georgia - call the 24-Hour, 7 days per week Georgia Crisis & Access Line (GCAL) @ 1-800-715-4225

Georgia & Florida - call the 24-Hour, 7 days per week National Crisis Line: 1-800-273-8255 

Georgia & Florida - go to your nearest emergency room

Couples Counseling

I do not offer couples counseling.

Children and Young Adult Counseling 

I do not offer counseling to anyone under the age of 18.

Structure of Sessions and Cost

I, Dr. Charles Greene, DBH, LPC, ACS, BC-TMH offer counseling face-to-face, via video conferencing,  and phone sessions. Telemental health is considered any of those methods other than on-site (face-to-face). If your counseling need is appropriate for telemental health, you can either solely receive counseling via one medium or any combination of them. Sessions are 50 minutes long but may at times need to be longer or even shorter. When arriving to your face-to-face appointment, please try to arrive no earlier than 10 minutes, as I would rather not have you waiting for long periods of time prior to your appointment. I do not have a designated waiting area, so individuals accompanying you should keep this in mind. For telemental health sessions, I will begin by verifying your identity with a pass code and your current location, which is necessary for emergency situations that may arise during our session. I am unable to conduct a session if you are driving or are in a moving vehicle and will terminate the session immediately. 

Cost per Session: $80 - $120  

***Note: The No Surprises Act was designed to prevent clients from unexpected medical bills. It states that if a provider is not in-network with a patient's insurance, then the provider needs to give the patient a "Good Faith Estimate" of how much they should expect to pay during their course of care. For behavioral health especially, it can be hard to judge an appropriate course of care upfront, so a generalized estimate is recommended of $100 per session, for 10-20 sessions, at 50 minutes each.  

Sliding Scale: Yes

Pay By: Cash, Discover, Health Savings Account, Mastercard, and Visa

The Square virtual terminal will be used for payment processing, which utilizes end-to-end encryption. Any payments you make to Red Pill Psychotherapy, LLC will NOT be credited toward satisfying any deductible you may be subject to under your health insurance plan with unless otherwise permitted under the terms of my health plan.

Employee Assistance Programs (EAP) and Wounded Warrior Project Programs, if pre-approved, will be covered through those specific programs. If you decide to start therapy, we will need to meet once per week for at least 4 sessions at an agreed upon schedule that works for the both of us. To begin treatment, clients must secure their account with a credit/debit card or pay in advance. Additionally, I will use the credit/debit card to process any cancellation or no-show fees, as a scheduled appointment is a significant commitment from your therapist. Clients must give at least 24-hours’ notice to cancel or reschedule their face-to face or telemental health appointment. If clients do not give a 24-hour notice, this is considered a 'NO SHOW' / missed appointment. Cancellation or no-show fees are charged at the same rate of the scheduled service.  

Pro Bone Publico

The American Counseling Association (ACA) encourages counselors to contribute to society by devoting a portion of their professional activities for little or no financial return; therefore, I do (when I have the availability) offer free face-to face and telemental health counseling sessions to individuals who demonstrate a sincere motivation but are financially unable to afford counseling services. 

Privacy Protocol During TeleMental Health Sessions

Always use a private and safe environment for your sessions. If someone enters your space during your session at your location, simply acknowledge their presence by saying hello and your clinician will automatically disconnect from the session. This is to protect your privacy. Inform your clinician if you would like to establish a different protocol.

Possible Limitations of TeleMental Health

Telemental health should not be viewed as a substitute for on-site counseling or medication by a physician. It is an alternative form of counseling with possible benefits and limitations. By acknowledging this document, you agree that you understand that telemental health:

1. may lack visual and/or audio cues, which may cause misunderstanding.

2. may have disruptions in the service and quality of the technology used.

3. may not be appropriate if you are having a crisis, acute psychosis, or suicidal or homicidal thoughts.

When you suspect that you may have misinterpreted your clinician’s statements, it is important to assume that your clinician has positive regard for you, and to check out your assumptions. This will reduce any unnecessary hardship. 

Emergency Management for TeleMental Health

So that I am able to get you help in case of an emergency and for your safety, the following are important and necessary. In addition, by acknowledging this document you are confirming that you understand and agree to the following:

1. You, the client, will inform me, your clinician, of the location in which you will be consistently during our sessions, and will inform your clinician if this location changes.

2. You, the client, will identify on your client information form a person, who I, your clinician, am allowed to contact in the case that I believe you are at risk. 

3. Depending on your clinician's assessment of risk, you, the client, or I your clinician, may be required to verify that your emergency contact person is able and willing to go to your location in the event of an emergency, and if I deem necessary, call 911 and/or transport you to a hospital. In addition, I may assess, and therefore require that you create a safe environment at your location during the entire time that you are in treatment with me. 

Backup Plan in Case of Technology Failure

If we get disconnected from a video conferencing or phone session, I will restart the session. If you and your clinician are unable to reconnect, your clinician will send you a message via the client portal. 

Termination and Referral Policy

You, the client, have the right to terminate the counseling relationship at any time and/or seek out a different therapist. I, the therapist, may terminate the counseling relationship if I determine that your condition is not appropriate for telemental health, if there are inappropriate boundary issues, if we agree that you have reached your goals and no longer need regular counseling and/or if your therapeutic needs fall outside the scope of my expertise.

There are certain issues that I will be sending you to see another therapist for; the most important for you to know about is the issue of suicide. If you have active or ongoing suicidal thoughts, have attempted to commit suicide in the past or have made plans to commit suicide, you need to see someone who specializes in this issue. If this comes up during our work together, I will end our sessions and refer you to a therapist (or other professional) who works with this issue. Other conditions include, without limitation, antisocial personality disorder, borderline personality or substance abuse disorders. Again, these conditions require specialized training and attention. If this comes up during our work together, I will end our sessions and refer you to a therapist (or other professional) who works with this issue.

Statement Regarding Ethics, Client Welfare & Safety

My services will be rendered in a professional manner, consistent with the ethical standards of the American Counseling Association (ACA). If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I encourage you to submit the complaint in writing to the Georgia Composite Board of Professional Counselors, Social Workers, and Marriage and Family Therapists at 237 Coliseum Drive, Macon, GA 31217-3858 or online at: http://verify.sos.ga.gov/verification. By acknowledging this document, you are indicating that you have read and understand the contents of this document. 

You acknowledge that you agree, have read and understood this document and agree to accept mental health services by, Dr. Charles Greene, DBH, LPC, ACS, BC-TMH.