Informed Consent Form And Confidentiality Statement

Psychotherapy: Participation incounseling can result in a better understanding of your personal goals and values, improved interpersonal relationships, and resolution of the specific concerns that led you to seek counseling. Counseling does involve some risks, including the possible experience of intense feelings such as sadness, anger, fear, or guilt. Please remember that these experiences are natural and normal, and they are an important part of the counseling process. Sometimes, in counseling, clients choose to make major life decisions, including decisions regarding family, relationships, employment and lifestyles. Decisions made during the counseling process may result in calling into question old beliefs and values, and these decisions may bring about changes not originally intended. The ultimate outcome of counseling cannot be guaranteed, however, most people report positive or neutral experiences after attending counseling.

Patients who are dependents: As the parent or guardian, you have a right and responsibility to question and understand what occurs in counseling with your child. It is also important that your child be able to trust the counseling process. Therefore, clinical discretion will be used with regard to what is appropriate disclosure of information. You can expect disclosure of information that is important to your child’s progress and to your participation in the treatment. If you are the custodial parent in a divorced relationship with your child’s other parent, please provide a copy of your court custodial order.

Confidentiality Statement: The contents of a counseling, intake or assessment session are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Confidentiality is between Counselor and the client in question. It is the policy of this office not to release any information about a client without a signed release of information. Following are the noted exceptions:

Duty to warn and protect: When a client discloses intentions or a plan to harm another person or self, the health care professional is required to warn the intended victim and report this information to legal authorities and make reasonable attempts to notify the family of the client.

Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client or any identifying information is not disclosed. Only relevant clinical information about the client is discussed.

When couples, groups or families are receiving services, separate files are kept for individuals for information disclosed that is of a confidential nature. This includes testing results, information given to the counseling professional not in the presence of the other person utilizing services, information received from other sources about the client, diagnosis, treatment plan, individual reports/summaries and information that has been requested to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each other’s presence is kept in each file in the form of case notes.

•Policy -
Termination of Services: Termination of counseling may occur at any time and may be initiated by either you or your counselor. Please contact your counselor if you decide to discontinue your counseling so that you can schedule for a final session. In case we don’t hear from you we will make two attempts to call and email to check in with you, if we don’t hear from you after these attempts and/or you report that you don’t need further sessions we will close your case. You can always reach out to the clinic in case you need therapy at any time in the future, appointment will be given based on availability of counselor. Termination itself can be a very constructive process, and we encourage you to discuss any plans to end counseling as soon as is necessary. If any referrals are warranted, they will be provided at that time.

Your rights: At any time, you may question and/or refuse counseling or diagnostic procedures or methods or request additional information regarding procedures. Please do not hesitate to discuss any concerns and/or complaints with your counselor so that we can work toward a resolution.

I agree to the above limits of confidentiality and understand their meanings and ramifications.

Please read and sign below:
I consent to participate in counseling services with with our mental health counselor and I agree to the policies of this office as detailed in the above paragraphs. I have had the opportunity to ask questions and clarify my understanding of these policies and there are no misunderstandings or disagreements.