4 Consent forms
Informed Consent for Telehealth Services
Welcome: Before starting, it is important to know what to expect and to understand your rights as well as your commitments. This consent form is intended to be transparent about the process so you are fully informed prior to beginning.
What to expect: Psychotherapy, counseling, and coaching involve a process of opening up about your life experiences and your genuine thoughts and feelings to increase self-awareness of psychological and emotional conflicts that may be keeping you stuck in unwanted patterns. It may involve temporary periods of discomfort as you begin to work through past experiences or confront conflicts you have previously been avoiding.
Fees: Sessions are billed at the rate listed at the time of booking. Payment terms are set by Bayle Russell.
Confidentiality: The information you share during sessions is considered confidential. Bayle Russell cannot reveal to third parties whether or not you are a past or current client, and cannot disclose any information discussed during sessions without first obtaining your consent. In some instances Bayle Russell may be required or permitted to share information without your consent, such as:
- If you are deemed to pose a threat of harm to yourself or someone else.
- If information shared leads Bayle Russell to believe that a child, elderly person, or disabled person is at risk for abuse, neglect, or exploitation.
- If you are under 18, your parents or legal guardians may have access to your records.
- If a court of law orders Bayle Russell to release information.
Your environment: You are responsible for ensuring you are in a private, safe, and distraction-free location during your session. Bayle Russell cannot guarantee the privacy of your physical environment.
Technology: Sessions are conducted over video and depend on a stable internet connection. Neither Bayle Russell nor Therapytips.org is responsible for technical disruptions beyond their control.
Notifications: When appointments are scheduled, automatic email reminders will be sent to the email address you used when booking. By agreeing to this consent form, you agree to receive these notifications and understand that email is not a fully confidential medium for transmitting health information.
Scope of services: Bayle Russell is qualified to work with a wide variety of clients and concerns, but there may be situations where they are not best positioned to address a particular issue. In these cases, Bayle Russell will work with you to identify appropriate resources. If you are experiencing a mental health crisis or medical emergency, please contact your local emergency services immediately — this service is not a substitute for emergency care.
Liability: By agreeing to this form, you consents to the above terms and agrees not to hold Bayle Russell, Therapytips.org, or their affiliates liable for any negative consequences that may arise from their therapeutic journey. you understands that Bayle Russell is an independent professional and that Therapytips.org is a booking platform and not a clinical service provider.
I practice under the supervision of Jeff Qua, LPC Supervisor, and am committed to providing compassionate, individualized care to help clients discover their strengths and achieve meaningful growth.
CONFIDENTIALITY
Your privacy is very important to me. I will treat everything you share in our sessions and in my records with care and respect. In general, what you tell me is confidential, protected by Texas law, professional standards, and my commitment to ethical practice.
However, there are some situations in which I am legally required to break confidentiality. These include:
• Risk of harm to self or others: If I believe you may harm yourself or someone else.
• Abuse or neglect: If I believe you are aware of or involved in the abuse or neglect of a child, or the abuse, neglect, or exploitation of an elderly or disabled person.
• Court orders: If a state or federal court orders me to share information.
Additionally, in the event of my death or disability, the Texas State Board of Examiners for Licensed Professional Counselors requires that my records be maintained by a designated custodian. Jeff Quan has agreed to serve as the custodian of my records and will follow the Board’s guidelines.
You also have the right to authorize me to share your information with specific people or agencies. If you sign a release form, I can provide information to the designated parties you request. I will never share your information without your knowledge and consent, except in the situations outlined above.
THERAPEUTIC RELATIONSHIP
Therapy is built on a genuine and trusting relationship between the client and therapist. This connection is the foundation through which growth, healing, and change can happen. At the same time, it is a professional relationship, and maintaining clear boundaries is essential for your safety and the effectiveness of therapy.
To keep our work focused and your therapeutic environment safe, I cannot engage in social relationships, friendships, or interactions with clients outside of our sessions. Limiting our relationship to the therapy space ensures that your therapy experience remains secure, consistent, and free from outside complications that could interfere with your progress.
The Therapeutic Process
My approach to therapy is tailored to meet the unique needs of each client. I enjoy working with women and men whom are adults, both individually and in groups, and I have experience supporting clients through trauma, mood disorders, coping challenges, grief, relationship difficulties, and self-development work. My approach centers on narrative therapy, expressive art therapy, and somatic techniques, while integrating strategies from CBT, DBT, mindfulness, and other modalities when helpful. Together, we will work collaboratively to help you explore your strengths, develop coping skills, and achieve meaningful growth in a safe and supportive environment.
FEES
Standard Session fee is $65.00 for a 50-minute session, and I ask that payment be made at the prior to each session.
I understand that sometimes finances can be a challenge. If needed, I am open to discussing a sliding fee scale for self-pay clients. We can work together to determine what is reasonable based on your situation.
If you need a letter or report regarding your sessions for medical programs or other purposes, an additional fee may apply.
SESSION GUIDELINES
Sessions typically last 50 minutes. If you need to cancel or reschedule an appointment, please provide at least 24 hours’ notice. If notice is not given, the full session fee of $65 may be charged. I understand that life happens, so I offer one-time leniency for a late cancellation or missed session. After that, the usual policy applies.
Sessions start and end at the scheduled time. If you arrive late, the session will still end as planned to respect your schedule and that of other clients. Likewise, I make every effort to be on time, and if I am delayed, I will make it right by extending time, prorating the fee, or offering another solution.
The frequency and length of therapy are decisions we make together based on your needs and goals. Each person’s therapeutic journey is unique, and the process will be tailored to what works best for you.
I offer telehealth sessions, Telehealth sessions follow the same standards of confidentiality and professionalism as in-person sessions, and I will provide guidance to ensure a secure and private environment.
Therapy is a journey of self-discovery and personal growth. Change often takes time, and progress may happen gradually. Being patient with yourself and staying engaged in the process can make a big difference in how you experience growth and achieve your goals. My role is to guide and support you as you explore your strengths, develop new skills, and create meaningful change in your life.
OUTSIDE CONTACT AND EMERGENCIES
You may leave a message for me on my confidential voicemail at 817-777-0677. I check messages daily and will return your call as soon as possible. Please note that this number is not for emergencies.
If you ever fear that you might hurt yourself or someone else, or if you are experiencing a mental health crisis, please seek help immediately:
• Call 911 for immediate emergencies.
• Suicide & Crisis Lifeline: Dial 988 (available 24/7).
MOBILE CRISIS RESOURCES
If you experience an urgent mental health crisis in the Mansfield area and need immediate assistance, you can contact the Metrocare Mobile Crisis Outreach Team. This team can be deployed to provide support based on your situation and level of urgency.
• Metrocare 24/7 Crisis Hotline: 214-743-1215
Local mental health authority of DFW Tarrant county
• MHMR Tarrant County Crisis Line: 817-335-3022
You may also contact the Texas Behavioral Health Executive Council if you have a complaint or concern about my professional services:
• Address: 333 Guadalupe St., Ste. 3-900, Austin, TX 78701
• Phone: 512-305-7700
• Toll-free 24-hour complaint line: 1-800-821-3205
Please feel free to ask me any questions about this information or any part of your care at any time