This agreement is intended to provide clients with important information regarding my professional services and business policies. This consent form will provide a clear framework for our work together and will facilitate our therapeutic relationship. Any questions or concerns regarding the contents of this agreement should be discussed with me before signing it.
Part I: Practice and Therapist Information
Professional Practice Orientation:
As a professional practice, we provide individual therapy for adults, adolescents, and children. We also provide couples therapy, family therapy, pre-marital therapy, group therapy, and parental training for clients in need of these services. depression, anxiety, post-traumatic stress disorder, self-mutilation, addictions, behavioral issues, self-confidence building, and relationship improvements are some of the many issues we can treat at our practice.
A therapist’s style of treatment is best rooted in the individual counselor’s experience and training. As a practice composed of many counselors, each counselor will utilize their own style and approach to treatment. Most of our counselors use an integrative approach, which allows for a more individualized treatment plan. Possible approaches may include but are not limited to Cognitive Behavioral Therapy (CBT), Solution-Focused Brief Therapy, Choice/Reality Therapy, Client-Centered and Mindfulness Based Stress Reduction (MBSR). The office is a great setting for therapy to take place with an eclectic theme that provides a comfortable and peaceful environment for healing to begin.
Educational/ Training Background:
Our practice is composed of both Licensed Therapists in the State of Ohio and board-approved Counselors in Training (CT). A counselor trainee is an individual seeking licensure as a professional counselor. To qualify for training status, they must be enrolled in a practicum or internship in a counselor education program. They must be of good moral character and complete the BCI & FBI background check. If you are working with a Counselor in Training as a clinician, please read the Counselor in Training Notice provided to you.
Part II: Client(s) Rights
1. You have the right to ask questions about any procedures used during therapy; if you wish, the therapist will explain their approach and methods to you.
2. You have the right to decide not to receive therapeutic assistance from any counselor within the practice; if you wish, the therapist will provide you with the names of other qualified professionals whose services you might prefer.
3. You have the right to end therapy at any time without any moral, legal, or financial obligations other than those already accrued. We ask you to contact us by phone or in-person before making such a decision without prior discussion.
4. You have the right to expect that the practice and therapist will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you, all of which would significantly compromise our work together.
5. Therapy involves a partnership between therapist and client. As your therapist, I will contribute knowledge, skills, and a willingness to do my best.
Associated Risk of Therapy
Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings, and experiences. The process may evoke strong feelings of sadness, anger, fear, etc. The issues presented by you may result in unintended outcomes, including changes in personal relationships. During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and change may be easy and swift at times but may also be slow and frustrating. Please address any concerns you have regarding your progress in therapy with your therapist.
Your appointment time is reserved especially for you. Therapy sessions are typically 50 minutes. Cancellations must be made 24 hours in advance; otherwise, you are responsible for an $80 fee. Regular attendance is recommended to ensure continuity and to enhance the effectiveness of the therapy. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
Email, Cell Phones, Computers, and Faxes:
It is especially important to be aware that computers, email, and cell phone communication can be relatively easily accessed by unauthorized people and, hence, can compromise the privacy and confidentiality of such communication. Emails are vulnerable to such unauthorized access because servers have unlimited and direct access to all emails that go through them. Additionally, the emails sent by me are not encrypted. We will only use computers that are equipped with a firewall, virus protection, and a password. Faxes can quickly be sent erroneously to the wrong address.
Records and Administrative Services:
Your therapist may take notes during the session and will also produce other notes and records regarding treatment. These notes constitute their clinical and business records, which by law, they are required to maintain. Should you request a copy of my records, such a request must be made in writing. The practice reserves the right under Ohio and/or Indiana law to provide you with a treatment summary in lieu of actual records when deemed clinically appropriate by the therapist. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. We also reserve the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider. We will maintain the client’s records for seven years following termination of therapy. If a client is a minor, records will be maintained ten years after the minor's eighteenth birthday. However, after seven to ten years, your records may be destroyed in a manner that preserves your confidentiality.