Katie Frazee, MS, LCPC, NCC, MAC
93 S McCain Drive, Suite 1
Frederick, MD 21703
240-415-8777 (Phone)
240-444-8075 (Fax)
1
Informed Consent
This document contains important information about my professional services and business policies. Please feel free to
ask any questions you may have regarding this document. Once you sign this document, it will become a binding
agreement between us.
Qualifications
I am a Licensed Clinical Professional Counselor approved by the Maryland Board of Professional Counselors and
Therapists. I am also a National Certified Counselor approved by the National Board of Certified Counselors and a Master
Addiction Professional approved by the Association for Addiction Professionals. In addition, I am a Licensed Clinical
Alcohol and Drug Approved Supervisor and a Licensed Clinical Professional Counselor Approved Supervisor, which enables
me to supervise other clinicians.
Available Services
Guiding Paths Counseling provides substance use and mental health services for adolescents, adults over the age of 18
and family members impacted by addiction and mental health issues. These services may include individual, group, family
and couples counseling. In some cases, following an initial assessment, recommendation may be given to pursue
treatment through another provider. In this event, you will be provided with referrals and assisted in the process.
Goal
The primary goal of Guiding Paths Counseling is to provide the most effective therapeutic experience available to you. The
purpose is to help facilitate behavior change by improving the client’s ability to establish and maintain relationships,
enhancing the client’s effectiveness and ability to cope, promoting the decision-making process, and facilitating client
potential and development. Clinicians cannot fix other people’s problems. Their job is to provide a safe and supportive
environment that allows the individual an opportunity to build the necessary skills needed to make informed and better
choices in their life.
Client/Counselor Relationship
You and your clinician have a professional relationship existing exclusively for therapeutic treatment. This relationship
functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your clinician can
best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. Gifts are not
appropriate, nor are any sort of trade of service for service.
Client Rights
1. You have the right to ask questions about any procedures used during therapy; if you wish, I will explain my approach
and methods to you. If I see a child under the age of consent (younger than age 16), all custodial parents have a right to
information shared in the session. Custodial parents should be aware that exercising this right may be detrimental to the
therapeutic process and, in turn, may wish to allow confidentiality to be maintained between the child and clinician.
2. You have the right to decide not to receive therapeutic assistance from me; if you wish, I can provide alternative
resources and names of other qualified professionals who may better assist you.
3. You have the right to end therapy at any time without any moral, legal, or financial obligations other than those already
Katie Frazee, MS, LCPC, NCC, MAC
93 S McCain Drive, Suite 1
Frederick, MD 21703
240-415-8777 (Phone)
240-444-8075 (Fax)
2
accrued. I encourage you to contact me by phone if this type of decision is made so we can discuss it.
4. One of the most important rights involves confidentiality: Within limits of the law, information revealed by you during
therapy will be kept strictly confidential and will not be revealed to any other person or agency without your written
permission. Additionally, when more than one family member is being seen in therapy, the clinician views the family unit
as the client. Therefore, releases of information for family sessions require the written approval of every consenting
member of the family who was present at any time during the treatment.
6. Upon your request, any part of your record can be released to any person or agency you designate with a signed
release of information. We will discuss whether or not releasing such information to that person or agency may be
harmful to you in any way.
7. You have the right to know about the possible harmful effects of therapy. Possible risks of treatment may include, but
are not limited to:
• No guarantee as to therapy outcome. Some people experience no improvement in their situation and a few may
even believe things are worse after treatment.
• The experiencing of intense and uncomfortable feelings as unpleasant events, relationship patterns, and other
concerns are addressed.
• Some health insurance companies will not cover the cost of counseling.
• When using medical insurance for psychotherapy, harmful events include: denial of insurability when applying
for medical and disability insurance due to a DSM-V diagnosis (mental illness diagnosis, which are usually
required for reimbursement under medical insurance); company (mis)control of information when claims are
processed; loss of confidentiality due to the large number of persons handling claims; loss of employment, and
repercussions of diagnosis in situations which require truthfulness about “mental illness,” including driver’s
licenses applications, concealed weapons permits, and job applications.
8. Everyone is expected to conduct himself/herself in a responsible manner. A session should not be held when anyone is
under the influence of a nonprescription drug, including alcohol. Violence is never acceptable. Either behavior may result
in discontinuing a session, or if necessary, calling the proper authorities.
9. Sexual relations between a client and his/her clinician are against the law. Racism, sexism, and other forms of
discrimination are not permitted.
The Therapeutic Process and Possible Benefits to Therapy
Therapy will seek to meet goals established by all persons involved, usually revolving around a specific presenting
problem. A major benefit that may be gained from participating in therapy includes a better ability to handle or cope with
daily stressors, as well as, family and other interpersonal relationships. Another possible benefit may be a greater
understanding of personal and family goals and values. This may lead to a greater maturity and happiness as an individual
and
increased relational harmony. Other benefits relate to the probable outcomes resulting from resolving specific concerns
brought to therapy such as reduced feelings of emotional distress, improved personal performance, reduction of health
and safety dangers, and more effective problem solving skills.
In working to achieve these potential benefits, therapy will require that firm efforts be made to change and may involve
experiencing significant discomfort. Therapeutically resolving unpleasant events and relationship patterns can arouse
intense feelings. Seeking to resolve problems can similarly lead to discomfort as well as relationship changes. If you
experience any of these feelings throughout the therapeutic process, please discuss this with your clinician.
Katie Frazee, MS, LCPC, NCC, MAC
93 S McCain Drive, Suite 1
Frederick, MD 21703
240-415-8777 (Phone)
240-444-8075 (Fax)
3
Confidentiality
1. There are certain situations in which a clinician is required by law to disclose information obtained during therapy.
Although I am not required to inform you of my actions in this regard, I will make every effort to do so prior to it
happening. All communication between you and your clinician will remain strictly confidential except in the following
circumstances:
• You authorize your clinician in writing to disclose information to a third party (i.e. your insurance company for
payment)
• If you reveal information relative to child abuse, child neglect, or elder abuse, I am required by law to report this
to the appropriate authorities
• When you threaten grave bodily harm to yourself or others, I have a duty to warn those you have threatened
and/or to contact law enforcement
• When a court of law issues a legitimate court order (signed by a judge)
2. Except in the above circumstances, I will release information about you only if you provide a written request. Releases
of information for families/couples in therapy require the written permission of every member of the family/couple in
treatment who is able to execute a waiver.
3. If I see a child under the age of consent (younger than 16), all custodial parents have a right to information shared in
the session. Custodial parents should be aware that exercising this right may be detrimental to the therapeutic process
and, in turn, may wish to allow confidentiality between the child and clinician. If a child’s parents are divorced or
separated, and have joint legal custody, I will require both parents to sign consent to treat the child even if one parent
does not have primary physical custody of the child. If the court has appointed an attorney to represent the child, that
attorney has the right to information shared in the session. If stated in a court order, that attorney has the exclusive right
to decide if information about the child’s sessions will be disclosed or not.
4. There are special confidentiality concerns for families and couples in treatment:
• I view the couple or family as the “treatment unit.” I cannot reveal any individual’s confidences to another
member of the treatment unit.
• It is important for you to be aware that “secrets” that are kept from family members are generally not healthy
for you or your family. For this reason, if an individual member or subset of the couple/family discloses a
confidence that has bearing on other family members, I will encourage the person(s) to reveal the information to
the other members. I will support you in finding ways to make such a disclosure.
• Should you reveal to me a “secret” that you refuse to disclose to the others and that puts me, by my knowing the
“secret,” in a position of hurting my honest relationship with others in the treatment unit, I will terminate the
therapeutic relationship.
5. In an effort to provide you with the best services possible and in accordance with state law, I attend a professional
supervision/consultation group. The professionals with whom I discuss my cases have access to confidential information
and are bound by the same confidentiality measures listed here.
6. In an effort to maintain your confidentiality and maintain professional boundaries, I will not acknowledge the existence
of the relationship outside of the therapy session unless initiated by the client. The therapeutic relationship is a
professional relationship and therefore will not be a social or business relationship at any time. Such a relationship, in my
view, would be detrimental to our purposes of therapy.
7. Client records are disposed of seven years after the file has been closed.
Katie Frazee, MS, LCPC, NCC, MAC
93 S McCain Drive, Suite 1
Frederick, MD 21703
240-415-8777 (Phone)
240-444-8075 (Fax)
4
Collaborating with Other Professionals
At times it may be important for me to contact other professionals who are helping you or your child. Such professionals
include, but are not limited to, teachers, psychiatrists, physicians, probation officers, and attorneys. I will not make such
contact without written permission.
In the event of my death or incapacitation, my Professional Executor may take control of records and contact clients.
Fee Schedule
Initial Assessment (45 minutes): $180
Group Session (45 minutes): $60/client
Individual Session (45 minutes): $160
Family/Couples Session (45 min): $160
*Sliding scale may be considered in certain circumstances. Please discuss this with your clinician*
There may be a charge for other services, including consultation with other professionals, preparation of reports or
correspondence, any necessary court appearances, phone calls lasting over 10 minutes, and missed appointments.
Clinicians have the right to seek legal recourse to recoup unpaid balances. In pursuing these measures, I will only disclose
minimal information, including, but not limited to, outstanding balances, in order to ensure confidentiality.
Financial Agreement
Please understand that you are financially responsible for your treatment and that payment is expected when services are
rendered at the end of each session. If payment for services that you receive is not made, the clinician has the right to
stop treatment services. Payments made are non-refundable.
Payment can be made through cash, check and all major credit cards. Checks can be made payable to Guiding Paths
Counseling. There is a returned check fee of $35 to cover bank fees.
Health Insurance Claims
If I do not accept your medical insurance, you can submit forms to your insurance company and may be eligible for
reimbursement from them. Since this may require a clinical diagnosis, I will discuss with you what this diagnosis is and
what it means so you can make an informed decision before submitting it to your insurance company.
Appointment Issues
If you are late for a session, the time of your session may be shortened, but you will still be required to pay for full time
the session was booked for you. I reserve the right refuse to see clients if they are more than 15 minutes late to their
session unless the client has called and provided a reasonable explanation for their tardiness. If the client does not show
for the session or if I deny services due to client’s tardiness, the client will still be responsible for the missed appointment
fee. If an emergency occurs that causes this, we can discuss those exceptions. See “Cancellation Policy” for how the
cancellations fees are determined.
Katie Frazee, MS, LCPC, NCC, MAC
93 S McCain Drive, Suite 1
Frederick, MD 21703
240-415-8777 (Phone)
240-444-8075 (Fax)
5
Cancellation Policy
A 48-hour cancellation notification is necessary for canceling or rescheduling an appointment unless there is an
emergency. If 48 hours notice is not given, there will be a $75 missed appointment charge, unless alternative agreements
have been made between client and clinician. Insurance companies do not cover the cost of missed appointments;
therefore, the client is responsible for this cost.
Legal Proceedings
To contain costs and focus on providing therapy, I do not offer court testimony, provide assessments, nor write qualifying
opinions for the court system on behalf of clients. I do not appear voluntarily for legal proceedings. If I am subpoenaed or
otherwise compelled to participate in proceedings, the cost of such services is $300 per hour, which includes time for
preparation. Additional travel costs may apply if I am travelling more than 20 miles from my practice location.
Communication/Emergency Contact
I am often not immediately available by telephone, email, or text during the day due to various reasons. When
unavailable, you can leave a message at 240-415-8777. This is a confidential voicemail and is monitored frequently. I will
make every effort to return your call within 24-48 hours with the exception of weekends and holidays. If you are difficult
to reach, please leave a return callback number or email I can reach you at. Email and texting are to be used for
scheduling and administrative purposes only. If you are in need of immediate assistance, please contact 911, the Frederick
County Crisis Hotline at 301-662-2255, or go to your nearest hospital emergency room. You can also contact 2-1-1 for any
crisis related concerns. If I will be unavailable for an extended period of time, you will be provided with the name of a
colleague to contact, if necessary.
Termination
Your clinician will discuss the appropriate time to terminate therapy with you. It is important that there be time given
before terminating to bring closure to the therapeutic relationship by talking about what has taken place during our time
together. If you wish to terminate treatment for any reason, I strongly encourage you to discuss this with your clinician to
determine if this is the most feasible course of action for you. If you decide to exercise this right, your clinician can assist
you with appropriate referrals and discharge planning.
Katie Frazee, MS, LCPC, NCC, MAC
93 S McCain Drive, Suite 1
Frederick, MD 21703
240-415-8777 (Phone)
240-444-8075 (Fax)
6
Consent to Treatment
My signature below indicates that I, __________________________________________________, am consenting to take
part in the treatment provided by Katie Frazee, of Guiding Paths Counseling, and I have received, agree and understand
the contents of the Informed Consent Form.
I understand that no promises have been made to me as to the results of treatment nor of any procedures provided by
this clinician. I am aware that I may stop treatment at any time, although I will still be responsible for paying any
outstanding balances for services received. I understand that if payment for services I receive is not made, the clinician
may stop treatment.
I agree to be financially responsible for all therapy sessions at the time of service. I agree to provide 48 hours notice to
cancel an appointment and if 48 hours notice is not made, I will be charged full fee for my missed appointment time. Full
fee is determined by the contracted rate with the insurance company. If you are not using insurance, full fee is
determined by the set rates mentioned in this form under “Fee Schedule.”
I am aware that an agent of my insurance company, or another third-party payer, may be given information about the
type, cost, dates and providers of the therapy services I receive. I understand that if my insurance company does not
make payment for services rendered, I will be responsible for any outstanding balances. If the outstanding balance is not
paid, I am aware that my clinician may stop treatment and, if necessary, has the right to authorize a third-party to collect
any unpaid dues.
I understand that in the event of my clinician’s death or incapacitation, the Professional Executor may take control of
treatment records and contact me.
I authorize email, text and phone communication unless otherwise agreed upon. I also authorize my clinician to leave
voicemails on my phone if needed.
My signature represents that all information has been explained and/or summarized for me by my clinician.
__________________________________________________ ___________________________
Client Signature Date
_________________________________________________ ___________________________
Guardian Signature (if applicable) Date
_________________________________________________ ___________________________
Clinician Signature Date
