INFORMED CONSENT FOR THERAPY AND COUNSELING SERVICES

GENERAL INFORMATION

The therapeutic relationship is unique in that it is highly personal in many ways – and at the same time – a professional relationship. Given this, it is important for us to reach a clear understanding of how our relationship will work and what each of us can expect.

This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

BEGINNING THERAPY

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 some discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc.

I cannot promise that your behavior or circumstance will change. I will promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

I think that its important that we have an initial conversation in our first session about our goals, our expectations, and decide if we are a good therapeutic fit. You may decide that my style is not right for you; I may decide that I may not be effective in helping you with the issues or problems you are presenting with. In either case, we will decide at the initial assessment and consultation if we both agree to move forward with treatment.

SERVICE DELIVERY

At this time, I am only providing services via telehealth through the online portal of online software called Simple Practice to clients who reside in Ohio. (If you live in Indiana, Kentucky, or some other place, then I’m unable to serve you at this time.)

SimplePractice’s setup is very user-friendly; you just need a device with a camera, microphone, and ability to click a secure link sent via email. See the Consent for Telehealth Services document for further information.

CONFIDENTIALITY

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

  1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
  2. If a client threatens grave bodily harm or death to another person.
  3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
  4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
  5. Suspected neglect of the parties named in items #3 and # 4.
  6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
  7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
  8. If the client discloses the commission of a felony.

CONSULTATION

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 but without using your name or other identifying information.

INCIDENTAL CONTACT OUTSIDE OF TREATMENT

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 in order to protect your confidentiality and my personal time off of work, we will need to keep those conversations brief and non-treatment related.

EXPECTATION OF PAYMENT

As this is a professional relationship, there is an expectation that you will pay for your services timely. If at any time finances become an issue, please address it immediately with me so we can discuss an appropriate plan to maintain your progress in treatment without incurring an overwhelming balance.

APPOINTMENTS AND CANCELLATIONS

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours.

Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

SOCIAL MEDIA

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from clients on any social networking site profiles (Facebook, Instagram, Twitter, Snapchat, LinkedIn, etc). Adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It’s important that you only contact me via encrypted or secure methods. I offer a client portal with secure messaging and utilize ProtonMail for encrypted email. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

If you need to contact me between sessions, please know that I am often not immediately available; however, I will attempt to return your call or message within 24 hours. I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. I do utilize secure email through a service called ProtonMail but prefer that once you are an established client that all communication occurs either through the secure portal at SimplePractice or, if necessary, by telephone at 513-202-3101.

MINORS

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. I also believe that it is essential for family and other support systems to be engaged in the therapeutic process, which we will talk about more as therapy progresses.

ENDING THERAPY

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment.

Either of us may terminate treatment therapy. I will only terminate therapy after an appropriate discussion outlining the rationale and detailing the termination process. This may happen if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating.

You may terminate therapy at any time. I hope that you will discuss any concerns you have, though, before ceasing services as feedback about the counseling process is helpful and imperative in order to maintain a healthy therapeutic relationship. If you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for 30 consecutive days, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

FINAL WORDS

If you have any questions about any of the above, please discuss it with Kirk. He’s happy to address any concerns and answer all questions so that you are comfortable and agreeable to entering into this therapeutic relationship.

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