Koppa Counseling

Informed Consent

  • Introduction:

    Welcome! The following information is to help establish the clarity, understanding, and trust essential to a good therapeutic relationship. Please read it carefully, as it contains important information about Koppa Counseling. Note any questions or concerns you have and they can be discussed before beginning therapy. After you sign this document, it will constitute a binding agreement between you and your therapist. This consent form is for psychotherapy. If you should want coaching, consulting, or supervision services please let your therapist know at the time of your meeting.

  • Part I: Therapist Information

  • Professional Orientation:
    Koppa Counseling provides therapy services to individuals, groups, and families. We work with people struggling with depression, anxiety, and life's emotional challenges. We specialize in treating individuals/families impacted by trauma, eating disorders, depression, and anxiety. We also work with adolescents and adults who have experienced trauma. We specialize in group and family issues such as parenting, step-families, communication, and relationship concerns. We often collaborate with physicians/psychiatrists and other medical professionals in order to help clients experience healing. We also work with school systems to facilitate relationships with parents, faculty, and students to help children/adolescents succeed. We also help women through the childbearing cycle (i.e.- infertility, miscarriage, stillbirth, postpartum depression, etc.).

    Our mission is to provide a compassionate, non-judgmental space where you feel free to express yourself. We value the uniqueness of the individual while fostering the health of the individual/family. We honor the whole of each of our clients as human beings by integrating the mind, body, and spirit.

  • Educational/ Training Background/Licenses:
    Dr. Koppa has have been providing therapy services to families, groups, and individuals since 2002. She has a Bachelor of Arts in Women’s Studies from Vanderbilt University (2000). She received a Master of Arts in Biblical Counseling from Dallas Theological Seminary (2003) and a doctoral degree in Family Therapy from Texas Woman’s University (2014). She has extensive training in treating Eating Disorders at all levels of care (inpatient, partial hospitalization, intensive outpatient, and outpatient therapy), as well as extensive experience working with adolescents struggling with depression and mood disorders, and their families, at all levels of care. She is currently a Licensed and Marriage and family therapist in the state of Texas (#201495) and a Licensed Professional Counselor Supervisor in the state of Texas (#59675).

  • Part II: Client(s) Rights

    1. You have the right to ask questions about any procedures used during therapy; if you wish, we will explain the approach and methods to you.
    2. You have the right to decide not to receive therapeutic assistance from Dr. Koppa; if you wish, we will provide you with the names of other qualified professionals whose services you might prefer.
    3. You have the right to end therapy at any time without any moral, legal, or financial obligations other than those already accrued. We ask you to contact Dr. Koppa by phone or in person before you make such a decision without prior discussion.
    4. You have the right to expect that Dr. Koppa will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you, all of which would greatly compromise the work done together.
    5. Therapy involves a partnership between therapist and client. As your therapist, Dr. Koppa will contribute knowledge, skills, and a willingness to do her best.
  • One of the most important rights involves confidentiality: within the limits of the law, information revealed by you during therapy will be kept strictly confidential and will not be revealed to any other person or agency without your written permission. Additionally, when more than one family member is being seen in therapy, we view the family as a whole as with the individual client. Therefore, releases of information for family sessions require the written approval of every consenting member of the family who are present during the session. As your therapist, Dr. Koppa is legally prohibited from revealing to another person that you are in therapy with her, nor can she reveal what you have said to her in any way that identifies you without your written permission. However, in the following instances, your right to confidentiality must be set aside as required by law and/or her professional standards.
  • Limits of Confidentiality:
    1. Instances of actual or suspected physical or sexual abuse, emotional cruelty, or neglect of a child or an elder or dependent adult must be reported to the appropriate protective services.
    2. If Dr. Koppa has a reason to believe that a client poses an unavoidable and imminent danger of violence to another person, She may warn the intended victim and notify the proper authorities.
    3. If you, as a client, reveal a serious intent to harm yourself, Dr. Koppa is ethically bound to do what she can to help maintain your safety, which may involve notifying others who may be of assistance.
    4. If a judge orders Dr. Koppa's testimony or, in the context of a legal proceeding, you raise your own psychological state as an issue, she may be required to release your confidential information to the court.
    In all of the above cases, it is incumbent upon her to release only that information necessary to appropriately carry out her responsibilities. Your confidentiality still remains the ethical priority.
  • Legal Action:
    If legal actions occur in which Dr. Koppa is requested or subpoenaed to provide testimony (such as a custody case), you will be responsible to pay Dr. Koppa directly for her services for providing the following: (a) the time spent preparing for court, (b) the time spent for transportation to/from court, and (c) the time spent appearing in court. Charges for legal services will be billed at $ 500.00 per hour. This fee is NOT reimbursable by a Third Party Payer and is therefore the full legal responsibility of the client and/or the client’s parent or legal guardian.

  • Part III: The Therapeutic Process

  • Benefits and Risks of Therapy:

    Psychotherapy is a process in which you and Dr. Koppa discuss a variety of issues, events and experiences for the purpose of creating positive change so you can experience your life more fully. Participating in therapy may result in a number of benefits to you, including, but not limited to, reduced stress and anxiety, a decrease in negative thoughts and self-sabotaging behaviors, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. There is no guarantee that therapy will yield any or all of the benefits listed above.

    Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. The issues presented by you may result in unintended outcomes, including changes in personal relationships. During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times, but may also be slow and frustrating at other times. Please address any concerns have regarding your progress in therapy with Dr. Koppa.

  • Appointments:
    Your appointment time is reserved for you. Cancellations must be made 24 hours in advance; otherwise, you are responsible for the session fee, in full. Regular attendance is recommended to insure continuity and to enhance the effectiveness of the therapy.
  • Telephone Accessibility:
    Dr. Koppa monitors messages frequently and will make every effort to return your call within 24 hours of when it is made. If you are difficult to reach, please leave times when you will be available. Should you have a true clinical emergency that requires immediate attention or action, you will need to call 911 or go to the nearest emergency room. Dr. Koppa's phone is unable to receive text messages, as texting is not HIPAA compliant in Texas.
  • E-Mail, Cell Phones, Computers and Faxes:
    It is very important to be aware that computers, E-mail, and cell phone communication can be accessed by unauthorized people and, hence, may compromise the privacy and confidentiality of such communication. E-mails in particular are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Additionally, the emails sent by Dr. Koppa are not encrypted. Faxes can easily be sent erroneously to the wrong number. Dr. Koppa only uses computers that are equipped with a firewall, a virus protection program and a password. Please do not use e-mail or faxes for emergencies. The office number is unable to receive text messages. Please do not text Dr. Koppa as there is no way to receive these messages and it will not be known it has been sent. Please communicate through email or telephone call.

  • Professional Fees and Payments:

  • We will discuss the fee structure and payment policy. Payment is expected at the time of each session. The current fee structure is as follows:
    Intake assessment: 60 minutes 250.00
    Individual therapy: 60 minutes 225.00
      45 minutes 195.00
    Group therapy: 60-90 minutes 95.00 per group
    Family therapy: 60 minutes 225.00
    Parent consultation: 60 minutes 225.00
    Telephone consultation: 10-19 minutes 75.00
      20-29 minutes 125.00
      30-45 minutes 175.00

    Dr. Koppa does do not charge for telephone consultations that are less than 10 minutes. Should it become apparent that additional sessions are indicated, we will increase the number of weekly sessions as needed.

  • CONSENT FOR SERVICES

  • Thank you for reviewing this information and please feel free to discuss any of this information with Dr. Koppa.
  • The signature on this disclosure statement indicates you have read and understood the conditions of the consultation services outlined. You have had the opportunity to clarify any questions and agree to the terms described above before receiving services. You have been provided with a copy of this disclosure statement.

Hillcrest Tower
12720 Hillcrest Road Suite 120
Dallas, Texas 75230

Contact

214-224-0970
214-224-0967 fax