Informed Consent for Counseling Services

Effective August 2026

Comprehensive Informed Consent for Counseling Services — Texas & New Mexico. 3:16 Behavioral Health & Wellness, PLLC, 111 S. 1st Street, Muleshoe, Texas 79347 — Phone: (806) 848-7316 — Email: info@316behavioralhealth.com — www.316behavioralhealth.com.

Provider disclosure & professional credentials

Your counseling provider is Andrés De Jesús “AJ” Soliz-Chávez, MA, NCC, LMHC, LPC Associate, of 3:16 Behavioral Health & Wellness, PLLC.

The Provider offers counseling services to clients physically located in Texas and New Mexico, subject to the Provider's applicable professional license and the laws and regulations governing counseling practice in the state where the client is physically located at the time services are rendered.

Texas professional disclosure

Andrés De Jesús “AJ” Soliz-Chávez is a Licensed Professional Counselor Associate (LPC Associate), Texas License No. 102148. As an LPC Associate in Texas, AJ provides professional counseling services under the supervision of Sandra Mireles, LPC-S, Texas License No. 82226 (Texas Licensed Professional Counselor Supervisor).

Clinical supervision may include consultation regarding assessment, diagnosis, treatment planning, interventions, ethical and legal considerations, client safety, continuity of care, and other matters related to professional counseling services. Information concerning a client's treatment may be discussed with the Provider's clinical supervisor as reasonably necessary for supervision and as permitted by applicable law and professional standards.

New Mexico professional disclosure

Andrés De Jesús “AJ” Soliz-Chávez is a Licensed Mental Health Counselor (LMHC) in the State of New Mexico, License No. CTB-2026-0369. Counseling services provided to clients located in New Mexico are provided pursuant to the Provider's New Mexico professional counseling license and applicable New Mexico laws, regulations, and professional standards.

Consent for counseling services

Counseling is a professional, collaborative, and voluntary process designed to assist clients with emotional, behavioral, relational, developmental, psychological, and other mental-health concerns.

Counseling may include assessment, treatment planning, psychoeducation, development of coping strategies, cognitive and behavioral interventions, exploration of thoughts and emotions, trauma-informed interventions when clinically appropriate, and other counseling techniques within the Provider's education, training, competence, and scope of practice. Your individual goals and treatment plan will be developed collaboratively and may be reviewed or modified throughout treatment.

Potential benefits — Potential benefits of counseling may include improved coping and problem-solving skills, increased insight, reduction in emotional distress, improved communication and relationships, increased emotional regulation, and progress toward individualized treatment goals. No specific therapeutic result or outcome can be guaranteed.

Potential risks — Counseling may involve discussing painful, stressful, traumatic, or emotionally difficult experiences. At times, counseling may temporarily increase feelings such as sadness, anxiety, anger, grief, frustration, distressing memories, or interpersonal conflict. Your Provider will work collaboratively with you to address these experiences and adjust treatment when clinically appropriate.

Voluntary participation

• Participate actively in decisions regarding your care;
• Ask questions regarding your treatment;
• Participate in developing and reviewing your treatment plan;
• Decline a particular therapeutic intervention;
• Request changes to treatment;
• Request referral to another qualified professional;
• Seek a second opinion; and
• Discontinue voluntary counseling services.

The Provider may recommend referral, transfer, a higher level of care, or termination when services are no longer clinically appropriate, treatment needs exceed the Provider's scope or competence, continued treatment is not therapeutically beneficial, or another circumstance permitted by law or professional standards exists.

Telehealth services

3:16 Behavioral Health & Wellness, PLLC provides counseling through telehealth as well as available in-person services. When participating in telehealth, you agree that:

• You will be physically located in a jurisdiction in which the Provider is legally authorized to provide services.
• You will accurately disclose your physical location at the beginning of each telehealth session.
• You will provide and maintain current emergency-contact information.
• You understand that the Provider may verify your identity and physical location.
• You will make reasonable efforts to participate from a private and appropriate location.
• You understand that technology may fail or become interrupted.
• You understand that no electronic communication system can be guaranteed to be completely secure.
• You understand that telehealth may not be clinically appropriate for every individual or circumstance.

If a telehealth session is unexpectedly disconnected, the Provider may attempt to reconnect through the telehealth platform or contact you using the telephone number on file. If contact cannot be restored and the Provider reasonably believes there is an immediate concern for your safety or the safety of another person, the Provider may contact your emergency contact, emergency responders, or another appropriate person or agency as permitted or required by law.

Emergency & crisis services

3:16 Behavioral Health & Wellness, PLLC is not an emergency or crisis-response service and does not provide 24-hour monitoring or emergency coverage. Voicemail, email, text messages, secure messages, and client-portal messages may not be reviewed immediately and should not be relied upon during an emergency.

• If you believe you or another person is experiencing an immediate medical or psychiatric emergency, call 911; or
• Go to the nearest emergency department.

The Provider may work with you to establish an individualized safety or crisis plan when clinically appropriate.

Confidentiality

Information disclosed during counseling and information contained in your clinical record will generally be maintained confidentially in accordance with applicable federal and state laws and professional ethical requirements. Confidential information may be disclosed without your authorization when disclosure is required or permitted by applicable law. Circumstances may include:

• Suspected abuse, neglect, or exploitation that must be reported;
• Serious or legally recognized threats or risks of harm;
• Valid court orders or other lawful legal process;
• Licensing-board investigations or other legally authorized proceedings;
• Clinical supervision;
• Treatment, payment, or healthcare operations as permitted by law;
• Situations in which you provide valid authorization for disclosure; or
• Other circumstances in which disclosure is permitted or required by federal or state law.

When disclosure is required or permitted, the Provider will seek to limit the information disclosed to what is reasonably necessary when applicable.

Couples & family counseling

When counseling involves couples, families, or multiple participants, confidentiality can become more complex. The Provider will clarify the nature of the professional relationship and, to the extent reasonably possible, identify who is considered the client at the beginning of services.

Participants should understand that the Provider cannot guarantee that another participant will maintain the confidentiality of information learned during a joint counseling session. Specific policies concerning individual communications, records, releases of information, and confidentiality during couples or family counseling will be discussed when applicable.

Minors & legal guardians

For minor clients, consent must ordinarily be provided by a parent, legal guardian, or another person legally authorized to consent to treatment unless applicable law permits the minor to consent independently. The practice may require copies of:

• Custody orders;
• Divorce decrees;
• Guardianship documents;
• Powers of attorney;
• Court orders; or
• Other documentation establishing authority to consent to treatment.

Applicable legal documents affecting consent, treatment, confidentiality, or access to records must be provided to the practice and may be maintained in the clinical record. The Provider will discuss confidentiality and its limitations with the minor and parent/legal guardian in a developmentally and clinically appropriate manner.

Records, record retention & continuity of records

3:16 Behavioral Health & Wellness, PLLC maintains clinical and administrative records related to services provided. Records are maintained electronically through a secure electronic health record system and are protected using reasonable administrative, technical, and physical safeguards designed to preserve confidentiality and prevent unauthorized access.

Client records will be retained for at least the minimum period required by applicable federal and state law and professional licensing requirements. When laws or regulations impose different retention periods, the practice will retain records for the longer applicable period.

3:16 Behavioral Health & Wellness, PLLC maintains a written records-continuity plan addressing the custody, security, retention, transfer, and appropriate disposition of client records in the event that the Provider dies, becomes incapacitated, terminates practice, or is otherwise unable to maintain responsibility for the records. In such circumstances, records will remain confidential and will be maintained, transferred, released, or ultimately destroyed in accordance with applicable law. A designated records custodian, personal representative, or other legally authorized individual or entity will administer the records-continuity plan and facilitate lawful client access to records when necessary. Clients will be provided reasonable notice and instructions for requesting records or arranging continuity of care whenever circumstances permit.

Questions or requests concerning records may be directed to: 3:16 Behavioral Health & Wellness, PLLC, 111 S. 1st Street, Muleshoe, Texas 79347 — Phone: (806) 848-7316 — Email: info@316behavioralhealth.com.

Notice of Privacy Practices

3:16 Behavioral Health & Wellness, PLLC maintains a separate Notice of Privacy Practices describing how protected health information may be used and disclosed and explaining your rights under applicable privacy laws. You will be provided access to the Notice of Privacy Practices through the intake process.

Communication policy

• Telephone, voicemail, email, text messaging, secure messaging, and the client portal may be used for appropriate administrative communications.
• Ordinary email and SMS/text messaging may not provide the same degree of privacy and security as secure healthcare communication systems.
• Email and text messaging should generally be limited to scheduling and routine administrative matters.
• Sensitive clinical information should preferably be discussed during counseling or through an approved secure communication method.
• Electronic communications must not be used for emergencies.

Social media & professional boundaries

To protect confidentiality and appropriate therapeutic boundaries, the Provider does not ordinarily accept personal social-media friend or follow requests from current clients. The Provider will not publicly acknowledge that an individual is or has been a client. Public social-media platforms should never be used to communicate confidential clinical information or request emergency assistance.

Financial agreement

• Payment is due according to the financial policies of 3:16 Behavioral Health & Wellness, PLLC.
• You are responsible for applicable deductibles, copayments, coinsurance, non-covered services, and balances not paid by an insurer or third-party payer.
• Verification of insurance benefits does not guarantee payment.
• Missed appointments and late cancellations may be subject to fees according to the practice's cancellation policy and applicable payer requirements.
• Administrative services not included in counseling may carry separate disclosed fees when permitted by law.
• A valid payment method may be required to remain on file according to practice policy.

Specific charges and financial policies are contained in the practice's separate Financial Agreement/Fee Schedule.

Good Faith Estimate

Clients who are uninsured or who choose not to submit services to their health insurance plan may have the right under federal law to receive a Good Faith Estimate explaining the expected cost of healthcare services. A Good Faith Estimate is not a contract and does not require you to receive services from this practice. Additional information concerning these rights will be provided as applicable.

Optional faith-integrated counseling

Faith-integrated or spiritually integrated counseling is optional. Religious, spiritual, theological, Scripture-based, prayer-based, or other faith-integrated interventions will be incorporated into treatment only at your request or with your informed agreement and when clinically appropriate. You are not required to participate in faith-integrated interventions as a condition of receiving counseling services.

At intake you will be asked to select one of the following:

• I would like faith/spirituality incorporated into counseling when clinically appropriate.
• I do not want faith/spirituality incorporated into counseling.
• I would like to discuss this with my Provider before deciding.
• I prefer not to answer.

Client rights & complaints

You have the right to raise questions or concerns regarding your treatment without retaliation. You may discuss concerns directly with your Provider, but you are not required to do so before contacting the appropriate licensing or regulatory authority.

Texas clients — Texas Behavioral Health Executive Council (BHEC), 1801 Congress Avenue, Suite 7.300, Austin, Texas 78701. Phone: (512) 305-7700. Complaints/Investigations: (800) 821-3205.

New Mexico clients — New Mexico Regulation & Licensing Department, Counseling and Therapy Practice Board, 2550 Cerrillos Road, Santa Fe, New Mexico 87505. Mailing address: P.O. Box 25101, Santa Fe, New Mexico 87504. Phone: (505) 476-4622. Email: counseling.board@rld.nm.gov.

Acknowledgment & consent

By electronically signing the consent form provided through the Client Portal at intake, you acknowledge that:

• I have read or had explained to me this Consent for Services.
• I have had an opportunity to ask questions.
• I understand the nature, purposes, potential benefits, and potential risks of counseling.
• I understand the limits of confidentiality.
• I understand the Provider's professional licensure status.
• If I am receiving services while located in Texas, I understand that Andrés De Jesús “AJ” Soliz-Chávez is an LPC Associate practicing under the supervision of Sandra Mireles, LPC-S (TX Lic. No. 82226).
• I understand the policies applicable to telehealth.
• I understand the practice's emergency and crisis policy.
• I understand that electronic communications are not appropriate for emergencies.
• I acknowledge that financial policies and fees have been or will be provided to me.
• I acknowledge receipt of or access to the practice's Notice of Privacy Practices.
• I understand that no specific therapeutic outcome has been promised or guaranteed.
• I voluntarily consent to receive counseling services from Andrés De Jesús “AJ” Soliz-Chávez through 3:16 Behavioral Health & Wellness, PLLC.

The signature line for the client or parent/legal guardian is provided on the electronic consent form completed through the secure Client Portal before the first appointment.