Informed Consent for Psychotherapy / Client Forms

Informed Consent for Psychotherapy

Please read this document carefully. It contains important information about my professional services and business policies.
When you sign this document, it will represent an agreement between us.

Informed Consent for Psychotherapy

PATIENT INFORMATION:

Full Name *

Date of Birth *

CURRENT ADDRESS:

Street Address *

City *

State *

Zip Code *

Phone Number *

Email address *

GENERAL INFORMATION:
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. It is important for us to reach a clear understanding about how our relationship will work, and what you can expect as my client. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.

THERAPEUTIC PROCESS:
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process,which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etcetera.

There are no miracle cures. I cannot promise that your behavior or circumstance will change. However, I can promise to support you in identifying the specific challenges you may be facing. I also promise to collaborate with you to create a customized plan of action to address these challenges.

Please acknowledge the statements below. *

I understand the general purpose and nature of psychotherapy.
I acknowledge that therapy may involve discussing unpleasant aspects of my life and may evoke strong emotions.
I understand that potential benefits include improved coping skills, better relationships personal growth.

CONFIDENTIALITY:
All information shared in therapy sessions is confidential, with certain legal exceptions.

These Exceptions Include:

Suspected child abuse or dependent adult or elder abuse.
If a client is threatening serious bodily harm to another person
If a client intends to harm himself or herself.
Court order.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy.

I have read and understand the limits of confidentiality.

FEES & CANCELLATION POLICY:
The standard fee for a 50-minute psychotherapy session is $180. Payment is due at the time of service.

A minimum of 24 hours’ notice is required for cancellation or rescheduling of an appointment. Appointments missed without 24 hours' notice will be charged a $75 fee.

No-Shows: Therapist will wait approximately 15 minutes (from the start of scheduled appointment time), for client to log on and start virtual session. After 15 minutes, and client still has not signed on, therapist will log off and will consider the session to be a "No-Show". Client will be responsible the $75.00 No-Show feefor the failure to attend scheduled appointment.

Please acknowledge the statements below. *

I understand and agree to the fee structure.
I understand and agree to the cancellation policy.

EMERGENCY PROCEDURES:
In case of a life-threatening emergency, please call 911 or go to your nearest emergency room. For urgent but non-life-threatening situations, you may contact the therapist at the provided phone number.

I understand the emergency procedures.

CLIENT SIGNATURE:
By signing below, I acknowledge that I have read, understood, and agree to the terms and conditions outlined in this Informed Consent form. I have had the opportunity to ask questions and have received satisfactory answers.

Client Signature (Type name): *

Date of Signing: *