Atlas Counseling - Check Up From The Neckup

“Check Up From The Neck Up” Informed Consent

Purpose of Check Up Neck Up

To provide individualized wellness and resilience training
Identify strengths and areas for improvement related to individual wellness and resilience
Learn early warning signs of poor mental wellness in self and colleagues
This is not a therapy session; should a therapy-related issue arise, you will be directed to make an appointment with Shannon Seibel or another mental health professional in an office setting.
No diagnosis is given during a check-in

Confidentiality and Documentation

All information shared is 100% confidential EXCEPT in mandated reporting situations
All information is 100% confidential from employer
Your name and contact information will be entered into a secure, HIPAA compliant electronic health record (EHR) and document the day and time we met, employer, and a copy of this informed consent document.
The purpose of notes has been explained to me and by my initials I state:
I do not want notes to include any personal details, rather it will simply state wellness related education was provided. I may request to review notes at any time.
I would like minimal notes recorded to help Shannon Seibel recall important aspects about me for future check-ups. These may include events, milestones, family make-up, support systems, strengths, resources, hobbies, or other helpful info. I may request to review notes at any time.

License and Grievance Information: Shannon Seibel is an Independently licensed LPCC (Licensed Professional Clinical Counselor) monitored by the Minnesota Board of Behavioral Health and Therapy. If you would like to file a grievance or complaint with the board, contact information is below:

Minnesota Board of Behavioral Health and Therapy
2829 University Avenue SE
Minneapolis, MN 55414

I have had the opportunity to review the above information and ask questions. By signing below, I am indicating that I have read, understood and am in agreement with the information in this document. I understand I do not have to provide any information I am uncomfortable giving, and can end the appointment at any time. Furthermore, I understand I can refuse recommendations given today.

First Name

Last Name

Client DOB

Client Signature