Consent for Treatment Form

I am excited you are choosing to pursue your journey for personal growth and wellness. I have written this to acquaint you with information relevant to counseling services, confidentiality and office policies. I will be happy to answer any questions you have regarding these statements.

Aims & Goals
The major goal of counseling is to help you identify and cope more effectively with problems in daily living and to address inner conflicts which may disrupt your ability to function at your highest potential. This purpose is achieved through various avenues and tools depending on your personal needs. No two people are the same; therefore, the avenues used for each will vary. Each person’s counseling agenda and goals will be individualized.

You are responsible for providing the necessary information to facilitate effective treatment. You are expected to play an active role in your counseling, including creating your counseling goals and assessing your progress. You will probably be given therapeutic homework. Your growth in counseling relies significantly on what you do between sessions. The more energy you put into your growth correlates directly to the amount of positive change achieved. I encourage you to take a very active role in your healing and growth.

Issues discussed in therapy are generally legally protected as both confidential and “privileged.” However, there are limits to the privilege of confidentiality. These situations include: 1) suspected abuse or neglect of a child, elderly person or a physically challenged person, 2) when your therapist believes you are in danger of harming yourself or another person or you are unable to care for yourself, 3) if you report that you intend to physically injure someone the law requires your therapist to inform that person as well as the legal authorities, 4) if your therapist is ordered by a court to release information, 5) when your insurance company is requesting records, e.g.: claims and billing issues, audits, case reviews or appeals, etc. 6) in natural disasters whereby protected records become exposed 7) or when otherwise required by law. You may be asked to sign a Release of Information so that your therapist may speak with other professionals or family member.

Appointment Scheduling
While many client’s make their initial contact and future session appointments over the phone, some are now using the many avenues of modern technology. Please know that if you chose to correspond with me for scheduling or otherwise via email or text messages that I will do what is within my power to keep those exchanges private. Please know that there are some inherit risks with using technology. While this has not been an issue it is important that you understand this if you use these forms of communication. Also, if I am asked to confirm or remind you of an appointment I often do that via email or text.

Record Keeping
A clinical file is maintained for seven years past your last date of service. This file includes general medical records, treatment notes, dates of services and notes describing our sessions. Client files are kept in a filing cabinet and also in a locked storage unit. Your records will not be released without your written consent, except for situations as outline in the Confidentiality section above. I do a portion of my billing along with using a billing company. This includes submitting all insurance claims. Client charts are taken to and from my home as I do some of my billing from my home office.

You have a right and are encouraged to share any complaints and/or concerns with any aspect of the counseling you are receiving. If you do not share these with me I will not know there is a problem or concern. My goal is to be helpful. This is a great opportunity to practice speaking for yourself in an assertive and respectful manner.

Consent for Treatment
By signing below, you are stating that you have read and understood this two-page statement and you have had your questions answered to your satisfaction.
You accept and understand the contents and terms of this agreement. You give consent to participate in an evaluation and/or treatment. You understand that you may withdraw from counseling at anytime. You also agree to talk with the therapist about any concerns or dissatisfactions that you may have.