6. If you request it, any part of your record in the files can be released to any person or agency you designate. I will tell you at the time whether or not I think releasing the information in question to that person or agency might be harmful in any way to you.

7. You should also know that there are certain situations in which I am required by law to reveal information obtained during counseling to other persons or agencies without your permission. Also, I am not required to inform you of my actions in this regard. These situations are as follows: (a) If you threaten grave or bodily harm or death to another person, I am required by law to inform the intended victim and appropriate law enforcement agencies; (b) If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in that order; (c) If you reveal information relative to child abuse, child neglect, or elder abuse, I am required by law to report this to the appropriate authority; and (d) If you are in therapy by order of a court of law, the results of the treatment ordered must be revealed to the court.

8. Most persons see me for counseling via self-referral. In such a situation there is no communication with outside persons without your written permission except as specified above in regard to the legal limits to confidentiality. However, If you are entering therapy with me because a representative of a District or Conference Board of Ordained Ministry, District Superintendent or Bishop has REQUIRED it, then the following procedures will apply:

(a) The referring person or agency will complete a referral for counseling and assessment form. The completed form should be forwarded to both of us from the referral source.

(b) At the beginning of our first session, you will be given the option for signing a Bilateral Authorization for Release of Personal Information Form. This is a written release of information that is required by law, which enables me to communicate in oral, and written form to the referring person or agency. You have the right to NOT sign this form. It is also time limited in that you may request it may be removed at any time.

(c) I will discuss with you at the beginning of therapy the possible positive or negative effects of your signing or not signing such a release of information. I will also work with you to find another counseling source if that is your desire.

(d) If you sign the release of information form, A copy of the form and a note from me that acknowledges that our work in counseling has begun will be sent to the referral agency or person.

(e) If you decide to not sign the release of information form, It will be your responsibility to communicate with the referral source about your decision.

(f) It is your responsibility to communicate with the referring person in regards to your progress in therapy. Normally this would involve a brief written statement pertaining to the original goals or concerns that precipitated the recommendation for therapy and your self perceived progress and growth. I will read your statement, and sign that I have read it.

(g) If you have signed an authorization of release of information, I will periodically send to the referring person or agency a formal response and assessment concerning your progress in therapy and situation. The information I forward will include data from both structured and unstructured assessment procedures. I will allow you to read the assessment that I will be forwarding on to the referring person. You may include an additional statement with my document specifying areas where you agree or disagree with what I have written.

9. You have the right to know about the possible harmful results of counseling. In my years of psychotherapeutic service delivery and supervision, the only clear harm I have witnessed has resulted from clients' insistence on using medical insurance for psychotherapy. Harmful events included: denial of insurability when applying for medical and disability insurance due to DSM-IV diagnosis (mental illness diagnosis, which are usually required for reimbursements under medical insurance); company (miss) 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 weapon permits, and job applications. The obvious benefit of utilization of the Conference Pastoral Counseling Center is that diagnosis for insurance reimbursement is NOT utilized. This level of confidentiality cannot be guaranteed when you go elsewhere for your counseling services and choose to use your health benefits.

1. Counseling and 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 counseling includes a better ability to handle or cope with marital, family, and other interpersonal relationships. Another possible benefit may be a greater understanding of family and personal goals and values; the may lead to a greater maturity and happiness as individual and increased relational harmony. Other benefits relate to the probable outcomes resulting from resolving specific concerns brought to counseling.

2. The Holston Conference Pastoral Counseling Center seeks to integrate professional counseling services and our United Methodist understanding of Christian faith and theology. This service exists for the mission of aiding and supporting the emotional, theological and relational well being of the clergy and clergy families of the Holston Annual Conference. Our spiritual lives are always a major focal point of our work and a crucial area in which we understand change to occur. You can expect your understanding of your own spirituality to be valued and welcomed as an important and vital resource for our lives and the counseling process. Indeed an important area for our growth as humans is to locate our selves spiritually and theologically within our families, places of ministry and the broader covenant community of the whole Church. Our conversations will most likely include all of these dimensions as you find them both relevant and appropriate.

3. In working to achieve these potential benefits; however, counseling will require that firm efforts be made to change and may involve the experiencing of 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 that may not be originally intended.

1. I agree to enter into therapy with Gary Mauldin, Ph.D.

2. I understand that I can leave therapy at any time and that I have no moral, legal, or financial obligation.

3. A twenty-four hour notice is requested for cancellation of a scheduled session. Please contact Dr. Mauldin at the telephone number listed above.

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