Hilton Wellness

I agree to enter voluntarily into a service contract with Christine Hilton, LMSW for services which have been fully explained to me; I understand that I am free to terminate this contract at any time. I understand that I have rights as a recipient of counseling service, that I have received a description of my rights and that I may discuss any questions I have on this topic with Christine Hilton, LMSW.

I agree to a 24-hour notice of cancellation of a session or I will be responsible for the fee for that session. I agree to come to sessions on time. I agree to pay for services at the time they are received. Payment options include Venmo (@Christine-HiIton-3), Zelle, or via Square with credit/debit card.

I agree to abstain from consumption of alcohol or mood altering substances for at least 24 hours prior to a session. I further agree to inform Christine at the beginning of the session if I have consumed alcohol/drugs within 24 hours of a session. I understand that I will not be seen for my scheduled appointment should I come to a session intoxicated.

I understand that the confidentiality of records maintained by Christine Hilton, LMSW is protected by 42 CRF Part 2 Federal Regulation. This information may not be disclosed unless the client gives consent. Information may be released without consent under the following specific conditions:

• Client threatens to harm self or others;

• Suspicion of child abuse or neglect;

• Medical personnel, to meet a bona fide medical emergency;

• Authorized by court order under Sub Part E-Section 2.61 of 42 CFR Part 2; Violation of the Federal regulation is a crime. Suspected violations may be reported to the appropriate authorities in accordance with Federal regulations. Federal regulations do not protect any information about a crime committed by a client either at the office/virtual platform of Christine Hilton, LMSW, or the threat to commit such a crime.

I agree to the following should I feel suicidal or homicidal: I will go to the nearest emergency room or call the National Suicide Prevention Hotline 1(800)273-8255 or dial 988 in Michigan. I will discuss these feelings with my psychiatric medication provider if I am seeing one, (as well as with Christine Hilton) and arrange for hospitalization if my psychiatric provider feels this is appropriate.

I understand that my record of service will be safely shredded, in accordance with privacy rules and regulations, seven years after the last session.

I agree to develop treatment goals and work to the best of my ability to achieve them. I understand that the results obtained through psychotherapy vary with each individual and no results can be guaranteed.

The goals I would like to achieve are: (list or discuss with therapist in session)