I consent that I am at least 18 years old and signing to each and every term in this agreement, with full and complete authority to act for Patient on whose behalf I am signing, consent to treatment services provided by Family & Addiction Counseling LLC located at 1888 Kalakaua Ave. Suite C312, Honolulu, Hawaii 96815.

In order for care to be effective, it is necessary for both provider and patient to take an active role in the treatment process.

Participation involves being open to each other's thoughts and ideas, being honest with each other, discussing concerns about the process, completing outside assignments when appropriate, and providing ongoing feedback to the provider about the process.

While treatment is often beneficial for many people, some people may not find services helpful. The treatment process can also evoke strong feelings and sometimes produce unanticipated change in one’s behaviors, thoughts, and feelings, family members, and friends.

In order for you to maximize your experience, it is helpful to discuss with your provider any questions or discomfort you may experience during therapeutic process.  You have the right to ask any questions, at any time, about what occurs during treatment.

You have the right to refuse the use of any treatment technique at any time.

Counseling and medical appointments are available throughout the week. If for some reason you are unable to contact your provider, you may obtain assistance by calling 911, the Crisis Help Line at (808) 832-3100 (Oahu) or 1-800-753-6879 (off-island), or by going to your local hospital emergency room.

You and your provider will collaborate on your frequency of sessions, number of sessions, goals, and type of treatment throughout the care process.

You and your provider may re-evaluate the frequency of your sessions as situations arise and/or as you move towards your goals.

We routinely check for voice and text messages during regular business hours and usually all calls are returned within 24 hours.

If your provider is not available immediately by phone, messages may be left at (808) 494-6066.  Text messages may also be sent to through our SMS scheduling system.

Under most circumstances, all information about you, in written or verbal form, obtained in the treatment process (including your identity as a client) will be kept ethically and legally confidential. Information will not be disclosed to any outside person(s) or agency without your written permission except in certain situations, which include, but are not limited to:

• If you are determined to be in imminent danger of harming yourself or someone else.
• If you disclose abuse or neglect of children, the elderly, or a disabled person(s).
• Diagnosis and services shared with your insurance company to collect payments.
• To qualified personnel for certain kinds of audits or evaluations.
• In cases where the client signs a release of information form.
• In court proceedings and where otherwise legally required.
• Information necessary for supervision or consultation.
• Information for business operations including accounting, data management, and laboratory testing systems.

Any information that you also share outside of treatment, willingly and publicly, will not be considered protected or confidential by a court.  The above is considered a summary. If you have questions about specific situations or any aspects of confidentiality, please feel free to discuss your concerns with your provider.