BEATRIZ LLORET’S INTAKE FORMS

I appreciate your decision to engage in counseling with me. I look forward to getting to know you and our working together on your goals. Building a therapeutic relationship is a key component in our work together and I have therefore addressed some aspects of how we will work together.

THERAPIST'S RESPONSIBILITIES

Within our first few sessions we will explore the issues and challenges that bring you to therapy and discuss what approaches we will take to assist you in reaching your goals. However, if I feel that my services are not appropriate for you, I will discuss this with you and refer you to other appropriate providers.

I endeavor to:

● Create a supportive and safe environment for you.

● Challenge you to try new ways of thinking, behaving, and feeling.

● Encourage honest feedback from you about our work together.

CLIENT'S RESPONSIBILITIES

I ask that you:

● Strive to be open and honest about your thoughts, behaviors, and emotions.

● Work between sessions on what we have done in our session.

● Give me honest feedback about my work with you.

● Keep your appointments and arrive on time.

CLIENT'S RIGHTS

The law protects the confidentiality of all communication between a client and therapist with certain exceptions. These exceptions are explained in the HIPAA NOTICE OF PRIVACY PRACTICES which you have read, signed, and been given a copy of.

During our therapeutic process, if you need to contact me, kindly leave a message or text me directly at (979) 575-9644, I will return your call as quickly as possible.

*If there is an emergency, please refer to the item Emergency Procedures on this contract.

CANCELLED/MISSED APPOINTMENTS

Your appointment time is an important commitment for both of us. Once we set a time, that hour is set aside just for you. If you are unable to keep an appointment, please call to cancel or reschedule at least 24 hours in advance.

There is no fee for rescheduling within the same week. There is no fee for rescheduling within the same week. If you cancel your appointment, you will be billed for 50% of your session for that week. If unable to cancel or reschedule 24hs in advance you will be billed for 70% of the session fee.

EMERGENCY PROCEDURES

If an emergency situation arises, please state that your call is an emergency.

The following referrals are for emergencies and situations that need immediate attention:

911 for any emergency assistance, 988 for National Suicide Hotline, or Nearest hospital emergency room.

PAYMENTS

Payment is accepted as cash, check or credit/debit card, and it's due at the end of each session, unless otherwise negotiated and agreed between us, and added in written to this contract.

INITIAL INTAKE BOOKING FEE

When you reserve a spot on my schedule that time is yours – meaning that most likely other couples will be waiting for their turn to get started and also that I am counting on that worked hour. You are responsible for a booking fee when you first schedule an initial Intake appointment with me. This is not an extra fee. You are only responsible for a $100 fee if you cancel your appointment or don’t show up to your appointment time. That fee will then be charged for the hour you reserved. I will not charge any fee if you cancel within 24 hours of booking.

FEES

50 minutes session $ 200.

75 minutes session $ 275.

95 minutes session $ 320.

COLLECTIONS NOTICE

 In case you fail to pay your due balance, I will make my best efforts to facilitate your payment, if this effort also fails I will send your balance to a debt collection agency.

ZOOM/FACETIME/EMAIL/VIDEO CONTRACT

It is important that you, as my client, understand the following limitations of Zoom/Face time/Email/Video contact, as well as expectations for each other we make for Zoom/Face time/Email/Video psychotherapy treatment:

1. Any internet-based communication is not guaranteed to be secure/confidential.

2. There are precautions that you, as my client, can take to increase security, including:

a.ensuring that you are online in a private room/area with the door closed, and if possible, using some type of sound blocking device;

b.when possible, connect to the Internet directly (as opposed to using Wi-Fi; this also helps with transmission);

c.make sure to turn Zoom/Face time/Email off and sign out at the end of the call when the session is over(not just disconnect from the call).

3. Make the same commitment to your online session that you would to an in-office appointment.

a. be on time;

b. limit distractions-turn off cell phones; avoid ‘spilt screens.’ Explain to others that you are unavailable for the next hour (perhaps hang a ‘Do Not Disturb’ sign on the door);

c. have your computer on a firm surface and sit on a sofa/chair or at a desk if possible;

d. the audio/visual in the ‘preferences’ each time before a session so that you can see what I am seeing (and vice versa);

4. An Online session is subject to our 24-hour cancellation policy. I have read the Zoom/Video/Facetime/Email Therapy Contract. I understand and agree to comply with the policies as they are described and acknowledge receipt of this contract. text goes here

EFT is a deeply experiential approach, which is why many EFT therapists choose to record and rewatch sessions. Revisiting the material gives us a second chance to reflect, track emotional patterns, and deepen our understanding of the couple’s process.

I record sessions with your consent so I can serve you better — often spending extra time reviewing parts (or all) of our work to gain insight and refine how I support your journey:

We consent to allow Beatriz Lloret, LPC to audio/video record our conjoint psychotherapy sessions. Beatriz has explained her commitment to improving the practice of couples therapy and how she plans to use the audio/video recordings.

We understand that the use and viewing of the audio/video recordings in whole or part is strictly limited to the following:

(1) analysis by Beatriz Lloret to optimize the quality of our care

(2) use by Beatriz Lloret for the purpose of professional consultation about our treatment or supervision on the quality of her EFT work.

We understand that our names will never be disclosed, and that only therapists who do not know us will be allowed to view the video recordings. We further understand that the video files are not part of our permanent medical record and that Beatriz Lloret will destroy each video file after it has been used for its intended purpose. We understand that either of us may withdraw our consent at any time.

PROFESSIONAL DISCLOSURE STATEMENT

Beatriz H. Lloret, M.A., LPC Licensed Professional Counselor, License # 71439, Texas

This document is designed to provide information concerning your counselor’s competency, philosophy, and chosen techniques

and to ensure that you understand the professional relationship of counselor and client.

PROFESSIONAL EDUCATION AND ADDITIONAL TRAINING

Bachelors of Science degree in Psychology from UNOESTE, Brazil and a Masters in Community Counseling with Emphasis in Marriage and Family Therapy from Sam Houston State University TX. Level 3 training on the Gottman Method of Couples Therapy. Advanced training and experience in Emotionally Focused Couples Therapy by the ICEEFT – International Centre for Emotionally Focused Couples Therapy.

AREAS OF COMPETENCE

Couples Therapy and Treatment of Anxious Attachment.

As your therapist, I hope to facilitate increased self-awareness and transformative emotional experiences intended to foster growth and change in your relationship.

TECHNIQUES

Because I believe that a client’s self-awareness and choices are key to developing self-direction and independence, my techniques will include Emotionally Focused Therapy supplemented by person-centered, systems techniques and neurobiology.

These techniques will provide methods to solve problems utilizing the client’s own strengths to meet their needs.

PROFESSIONAL RELATIONSHIP

While our sessions might be very intimate psychologically, it is important for you to understand that we have a strictly professional

relationship rather than a social relationship. Our contacts, other than chance meetings, (where I will not greet you, only respond if

you decide to do so, in order to protect your privacy) will be limited to appointments we arrange. I will not attend your social gatherings,

accept gifts from you, or relate to you in any other way than in the professional context of our counseling sessions. You will be best served if our relationship remains strictly professional and our sessions concentrate exclusively on your concerns. While you might learn much about me as we work together, it is important for you to remember that you are experiencing my professional role.

CONFIDENTIALITY

I will keep confidential the things you tell me, with the following exceptions: (a) you direct me to tell someone else, and I agree to do so; (b) I decide you are a danger to yourself or others; (c) I am ordered by a court to disclose information; (d) you disclose abuse of a child, a disabled person, or an elderly person; (e) you disclose that a previous therapist sexually exploited you; or, (f) other reasons as specified in laws of Texas. Confidentiality also does not extend to criminal proceedings or to legitimate subpoenas in a civil proceeding. If needed, in order to provide you with the best quality of services possible, I may eventually have consultations about

your case with other qualified professionals, while actively protecting your identity. I am committed to honor your trust in my professional work and will aways protect your confidentiality. I practice my work using the highest ethical standards. If I ever need to discuss your case with other professionals (physicians, psychologists, etc.) rest assured that I will always follow the HIPPA regulations, discuss it with you first and will only do it with your written consent to do so.

OTHER

It is my intention to render my services in a professional manner consistent with accepted standards of practice. Our sessions will last between 50, 75 or 90 minutes, as scheduled in advance. It is impossible for any counselor to guarantee any specific results regarding your counseling goals. However, together we will work to achieve the best possible results for you and your partner.