Informed Consent

Informed Consent

The purpose of this form is to set parameters and guidelines within which this practice functions.  Please read this form before signing at the bottom.

1.  Confidentiality – Counseling sessions are confidential.  Confidential means that I/we will not share any information that you disclose in these counseling sessions to third parties without written consent.  The only exceptions in this practice are as follows:

  • If you present an imminent risk of serious harm to yourself or to someone else, the law requires that steps be taken to prevent such harm;
  • If you disclose information about child abuse or neglect, a report must be filed with appropriate agencies or authorities;
  • If a court orders the disclosure of records;

In order to provide you the best service, I receive ongoing supervision from my therapist peers and trainers. Your case may be discussed in this private context with the understanding that any identifying details are changed to ensure your complete anonymity and confidentiality.

2.  Length of appointments–On-going sessions typically are one hour, but longer sessions may be recommended by the therapist or requested by the client.

3.  Cancellation or Rescheduling – Both require twenty-four (24) hours advance notification. If cancelled less than 24 hours, the client will be invoiced for the session.

4.  Payment of services – My fee is $_140_ per hour.  Billable services include face-to-face and telephone consultations (does not include initial telephone in-take or scheduling), report writing, and review of written records from other psychologists/therapists/professionals.

5.  Payment is required at the end of each appointment.  Cash or cheques are accepted.  I will issue a receipt upon payment.  I will carry overdue for three (3) months (with interest charged at 1.5% per month) before I initiate a more formal collection/legal action.

SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND UNDERSTOOD THE CONTENT OF THIS FORM*:

*I will present an actual form to be signed in my office

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