archived forms & practice information

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The following is a revised version of earlier forms identified below. The original forms are still showing as they are actively in use by many current and former clients and will remain available for review. Existing clients are being transitioned off these forms and onto the more current versions. 

Deborah Beckman, MS, LPC, NCC is a private practice that provides therapeutic services. The therapeutic relationship can be described by the scope and limits of confidentiality. Confidentiality is the act of holding anything said or done within the therapy session as private. Therapy is an intense personal relationship that relies on a therapist maintaining professional standards and limits. There is no social relationship possible. You are free to discuss your therapeutic experience with individuals in your personal life. You are free to ignore or acknowledge me should you encounter me outside of session and in a public space.

The conditions that limit confidentiality are: (1)it is determined that you are a danger to yourself; (2)it is determined that you are a danger to someone else; (3)you have information regarding abuse or are abusing a child or other dependent person; (4)you have provided written permission for disclosure of information; (5)court ordered release of information; (6)information pertinent for clinical supervision or consultation (all clinicians are bound by the same scope and limits of confidentiality). If clinically advisable, you will be informed of action taken with regard to the limits of confidentiality. 

I will be working with you to clarify and establish goals; however, no one can offer a guarantee that your goals will be accomplished. For some clients, only a few sessions may be required while other client may require years of consistent therapy. You have the choice to end your therapy at any time. It would be beneficial to have a final session to summarize and terminate the relationship. Every effort will be taken to be on time and ready for your session to begin and the same commitment is asked of you.

How to Contact Me

The most effective ways to get in touch in a reasonable amount of time are:

• By phone at 214.824.2009. You may leave messages on voicemail, which is confidential. This is the best and most consistent means of contact.
• By secure messaging through thera-LINK
• If you wish to communicate with me by regular email or regular text message, please read and complete the Consent For Non-Secure Communications section of this form.

thera-LINK is a “client portal” service that allows us to communicate securely through the use of encryption and other privacy technologies. There is no fee. It requires some setup before it can be used. This is not an “instant” form of communication. 

If you need to send a file such as a PDF or other digital document: 

• send using the thera-LINK secure client portal document service. 
• print and FAX it to 214.824.2081.

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

It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.

Response Time

I may not be able to respond to your messages and calls immediately. For voicemails and other messages, you can expect a response within 24 hours. (weekends/holidays are excepted from this timeframe.) I may be able to reply more quickly than that, but please be aware that this will not always be possible.

Be aware that there may be times when I am unable to receive or respond to messages, such as when out of cellular range or out of town. When possible, you will be informed. My voice mail message has current information.  

Emergency Contact

If you are ever experiencing an emergency, including a mental health crisis, please call 

Suicide and Crisis Center of North Texas at 214.828.1000. 

Additional crisis services are listed on my website, DeborahBeckman.com on the Depression page. Become familiar with them prior to any need.

If you need to contact me about an emergency, the best method is by phone 214.824.2009

Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole method of communicating with me. This is especially true for an emergency.

Disclosure Regarding Third-Party Access to Communications

Please know that if we use electronic communications methods, such as email, texting, online video, and possibly others, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.

Of special consideration are work email addresses. If you use your work email or phone to communicate with me, your employer may access our communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with. Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages we exchange with each other. 

Email and Text Risk Questionnaire

This questionnaire is for you to read on your own. I am ethically bound to meet the threshold set by the 2014 ACA Code of Ethics for informing clients of risks involved in the use of digital and networked communications technology. This questionnaire is to help you think about the risks involved and structure a discussion with me to determine what is acceptable. The final purpose of such a discussion would be to:
Help determine if the risks involved in email and/or texting are acceptable and/orHelp find what needs to be done to reduce the risks to reasonable levels. E.g. you may limit what kinds of communications are acceptable, may choose to use a different email address, etc.

Regarding Email

1. Technical experts often describe email as being like a postcard, in that it can be viewed by all hands it passes through. Are you familiar with the risks of emails being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
2. Think about where you read and write emails, and what devices you do that on. Think about who can see you reading and writing emails in these places, and who can access the devices you use to read and write emails. Would there be any negative consequences to any of those people reading or glancing at emails exchanged with your therapist? Are there certain kinds of email contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use email with him or her.
3. Think about which email address(es) you might use with your therapist. Who has access to each address? If you use a work email address, know that your employer may legally view all the emails your send receive with that address. Be aware that engineers and administrators at your email service provider may be able to view your emails.
4. How quickly do you normally receive replies from others via email? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to an email as quickly as others in your life typically do?

Your therapist’s email service are through these companies:  thera-LINK for secure “client portal” communication. Professional business email is through regular channel Gmail.

Regarding Texting

1. Text messages are often sent using the Internet, even though they are usually a part of one’s phone service. Are you familiar with the risks of texts being viewed by various engineers, administrators, and bad actors as it passes through the Internet?
2. Are you aware that text messages wait on phone company computers until they are retrieved, and may remain there indefinitely? Can you imagine any negative consequences if engineers, administrators, or law enforcement personnel viewed these stored texts from or to your therapist?
3. Think about where you read and write text messages, and what devices you do that on. Think about who can see you reading and writing texts in these places, and who can access the devices you use to read and write texts. Would there be any negative consequences to any of those people reading or glancing at texts exchanged with your therapist? Are there certain kinds of text contents that you would feel safe letting these people see and other kinds of contents you would not feel safe letting them see? Let your therapist know the answers to these questions if you wish to use texting with him or her.
4. How quickly do you normally receive replies from others via text? Do you expect replies more quickly than your therapist’s stated response time? Can you see any negative consequences occurring if your therapist does not or cannot reply to a text as quickly as others in your life typically do?

Your therapist uses the following device(s) and phone service(s) to send and receive text messages: iPhone SE with T-Mobile

Note that there are some interesting effects depending on what devices you and clients use. For example, if your client and you both use iPhones, then your text messages may not be typical SMS text messages. Instead, your messages may be iMessage chat messages. On iPhones, iMessage chats are colored blue, while classic SMS text messages are colored green.

I choose to communicate with you by (initial all that apply):

_____ office phone & voice mail - required primary contact information

_____ client phone & voice mail - required primary contact information

_________________ preferred client phone for contact

_____ thera-LINK client portal email for practical matters

_______________________ preferred client email for contact through thera-LINK 

_____ text to cell phone for practical matters

I prefer to receive mail at ______________________________________________

I prefer to receive email at ______________________________________________

Content adapted from PersonCenteredTech.com material 2020

This is designed to allow you to give informed consent for the use of video technology for online therapy. Read it thoroughly for understanding and ensure all of your questions are answered before signing to give consent.

This is to be used in conjunction with, but does not replace, the Intake Questionnaire and Consent for Treatment document that is required of all clients prior to starting therapy services.

Online therapy or tele-therapy is defined as the use of technology to have a therapy session. We will use thera-LINK, a HIPAA compliant platform that uses video and audio technology through a webcam on your device and my device.

thera-LINK uses encrypted data streams (AES-256) for our video sessions. Any data that is stored outside of our video session on the thera-LINK platform (such as documents, messages, or progress notes) is encrypted and meets or exceeds all HIPAA and HITECH guidelines.

The benefits of tele-therapy include the convenience of location, time, wait times, and accessibility which allows for better continuity of care. In addition, tele-therapy allows for greater accessibility to services for clients with limited mobility or with lack of transportation. Tele-therapy can also allow for couples or families to meet when in different locations.

With all technology, there are also some limitations. Technology may occasionally fail before or during our session. The problems may be related to internet connectivity, difficulties with hardware, software, equipment, and/or services supplied by a 3rd party. Any problems with internet availability or connectivity are outside the control of the therapist and the therapist makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video, the therapist will either use the in-session video chat to trouble shoot or will call you back to complete the session. Please list your main number and an alternate number here: _______________________________________.

If, for any reason, we are unable to connect and you are in an immediate crisis or a potentially life-threatening situation, get immediate emergency assistance by calling 911.

I AGREE TO TAKE FULL RESPONSIBILITY FOR THE SECURITY OF ANY COMMUNICATIONS OR TREATMENT ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. 

I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allow another person to use my user ID to access the Services. 

I understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.

I understand that there will be no recording of any of the online session and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

I understand that I am not allowed to do any recording, screenshots, etc. of any kind, of any session, and are grounds for termination of the client-therapist relationship.

Consent to Treatment

I, voluntarily agree to receive online therapy services for an assessment, continued care, treatment, or other services and authorize Deborah Beckman, MS, LPC, NCC to provide such care, treatment, or services as are considered necessary and advisable. I understand and agree that I will participate in the planning of my care, treatment, or services and that I may withdraw consent for such care, treatment, or services that I receive through Deborah Beckman, MS, LPC, NCC at any time. I understand Deborah Beckman, MS, LPC, NCC will determine on an on-going basis whether the condition being assessed and/or treated is appropriate for online therapy. 

By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

I am responsible for maintaining the ethical guidelines of practice as established by the Texas State Board of Examiners of Professional Counselors. You are encouraged to address any complaints or dissatisfaction directly with me. However, should your complaint not be resolved, please notify the Texas State Board of Examiners of Professional Counselors at 800.942.5540.

Appointments are typically 55 - 60 minutes in length. Your fee for sessions, based on a sliding scale published on my website, will be ______ and due at the time of service unless other arrangements are made. 

Fees will be due for appointments missed without a minimum of 28 hours notice.

I, the undersigned, understand and agree to all of the above. I understand that this

Information & Policies for Informed Consent for Treatment

is available at any time on DeborahBeckman.com