Now Offering Online Virtual Counseling

INFORMED CONSENT AND CONFIDENTIALITY STATEMENT


I understand and agree to the following:

  • that treatment offered is voluntary in nature, unless I am under the age of 18.
  • that, within certain limits, information that may be revealed during therapy will be kept strictly confidential, requiring a written authorization from all parties in treatment if any information is to be released to any outside parties, with the exception of my insurance company.
  • that if I reveal information indicating that I may be a threat either to myself or others, my therapist may be permitted and/or mandated by law to reveal this information to other persons or agencies for the safety of myself or others. This would include instances of suspected child abuse when treating a child under 18 years of age.

  Telemental Health Information -  

  • We may be using certain technological services and tools, such as Facetime and Zoom.
  • Telemental health has both benefits and risks, whilch you and your provider will be monitoring as you proceed with your work.
  • You can stop work by telemental health at any time without prejudice.
  • You will need to create a private and appropriate space for your sessions.
  • You will need to make a plan for managing technology failures, mental health and medical emergencies.
  • Your provider follows security best practices and legal stsandards to protect your health care information, but you will also need to maintain your own security and privacy.

Financial Policy

PAYMENT IS DUE IN FULL AT THE TIME OF EACH SESSION. FEES ARE SUBJECT TO CHANGE EVERY SIX MONTHS.

NO-SHOW AND CANCELLATION POLICY  - Your visit has been reserved for you. 24 hours notice is required for cancellation or you will be charged a late cancellation fee of $75.00.

By clicking the Submit button, I acknowledge that I have read and understand this information sheet and informed consent.  

MCP_______               

EVAL_______               

If you would like to receive the Couples Guide Newsletter containing articles on relationships , please sign up below.


Visit  The Relationship Forum  to get and give advice on your relationship issues.

If you're struggling with your relationship, this is the place to talk about it!
Our counselors will answer your questions.
And you, our readers, can offer advice from your experience.