Informed Consent Document (Example)


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Chances are, if you choose to pursue the counseling profession, you will be required to produce a document of Informed Consent.  The document pretty much speaks for itself, but it really represents all the things you should probably know before you enter into therapy.  If you engage in therapy and you do NOT get an informed consent document, or, if the one you do get doesn’t address an issue that is contained here but still concerns you… you should definitely ask your therapist to qualify on that particular point.

Purpose of Informed Consent

This document has been provided as an explanation of the services I provide.  The intent is to allow you to make informed and autonomous decisions pertaining to the counseling process.

Qualifications

My name is Kent Brooks.  I currently hold a Bachelors Degree (BA) from the University of Northern Iowa in Education.  I also hold a Master of Science (MS) degree in Clinical Counseling from Bellevue University.  My title is Provisional Licensed Mental Health Professional.  Because of the provisional nature of my license, my practice is currently supervised by XXXX LMHP.  Her information is available upon request.  While I have significant experience and training, I sometime find it necessary to refer a client to another more qualified professional.  If a referral is in order, I will inform you and discuss possible options.  You may request to be referred to another counselor at any time.

Counseling means Collaboration

Counseling is a collaborative process between you and a counselor where mental health distresses and disorders are evaluated, assessed, and treated.  For therapy to be most effective, it is absolutely essential that you take an active role in the process.

Risks

The counseling process may open up levels of awareness and provoke realizations that may cause uncomfortable feelings, sadness, guilt, anxiety, anger, pain, frustration, loneliness, and/or helplessness.  In some cases major life decisions are made, in others traumatic events are reflected upon.  This process of growth and self actualization can cause significant impacts to employment, lifestyles, and relationships.  Psychiatric services are inexact sciences; we make no guarantees/warranties, regarding outcomes.

Appointments

Sessions are generally scheduled in 50 minute increments, once per week.  Once an appointment is made, it is assumed to be a recurring appointment.  Some situations may justify modification of the schedule, thus increasing or decreasing frequency of appointments.  Being late for an appointment by 25 minutes or more may require that you reschedule.  If you need to cancel an appointment, please contact me at 402-990-6905 at least 24 hours in advance.  Cancellations with less than 24 hours notice will be charged a $50 no-show fee.  We reserve the right to terminate the relationship in the event that 2 consecutive appointments are missed without notification of cancelation.

Fees and Payment

Co-payments with approved insurance, or payment in full, will be collected at the time the service is rendered.  The standard fee for a single 50 minute session is $95 USD.  Checks returned for insufficient funds may be subject to an additional $35 fee.  If you are subject to undue financial stress, you may request a fee adjustment based on a sliding scale so that we can continue to accommodate your needs.

Confidentiality

Your confidentiality is important to me.  The nature of the counseling profession, and the ethics and laws that govern it, presents certain limitations that need to be both acknowledged and addressed.  All communications between a mental health professional and a client are protected by law. If required or requested, I will release information regarding our communications to others with your express written consent.  (Release of Information form)  If you are under 18, your parents or legal guardian(s) may have access to your records and may authorize release to 3rd parties.

Diagnosis

Most 3rd party payers require that I provide a diagnosis to describe your condition.  Once that information is provided to insurance companies, I can accept no liability for impacts to insurability or employment.

Mandatory Reporting

Mandatory reporting requires me to report situations where the client is a danger to self or others.  Situations in which a child, elderly, or disabled person is subject to abuse or neglect are also subject to mandatory reporting.

Records

I am required by law to maintain detailed records each time we interact.  They records contain sensitive information including observational data, diagnosis, treatment plans, and other clinically relevant information.  During the course of treatment, information may be provided to insurance companies, managed care companies, and/or courts.  I will share records, in full or in part, with you as the client if requested; unless the determination is made that it may hinder progress or otherwise cause undue harm.

Consultation

I may consult with other professionals (legal and clinical) on your case.  To what degree it is possible, every reasonable attempt will be made to avoid revealing your identity to other professionals with whom I consult.  Because my license is currently provisional, it should be expected that I will regularly consult with coordinating and/or supervising personnel, listed above.

Termination

Termination of the counselor-client relationship can occur in several different contexts, but it is important that we be prepared for a termination phase from the outset of treatment.  You can choose to terminate therapy at any time.  You have a right to expect that the relationships will be terminated when you have realized maximum benefit from it, or have achieved the goals that are made at outset.

Managed Care Limitations

I am committed to providing the highest quality care available; however, limitations on my ability to provide that level of care are sometimes affected by insurance and/or managed care providers.  Limitations can affect the therapy process, length of treatment, number of sessions, and amount of money that will be reimbursed.  In some cases managed care guidelines may affect the content of the therapy.  These considerations, if they apply, will sometimes affect outcomes.  In addition, if you wish to utilize a 3rd party payer, I must be able to discuss your diagnosis and treatment with representatives of your EAP, managed care, or insurance.

Emergencies

In the event of an emergency, for which you feel immediate attention is necessary; I will make reasonable effort to make myself available.  If I am not immediately available and you reach voicemail, please leave a message indicating that the call is urgent.  Please contact 911 immediately or proceed to the nearest emergency room for immediate evaluation.

I have read, understood, agree, and consent to the above conditions of service.  I have had the opportunity ask questions regarding the above policies.

Client Signature________________________________Date_____________________________

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About Kent Brooks

try-therapy.com is a group of helping professionals collaborating to bring you information about mental health, counseling, and therapy! We provide therapy and mental health services throughout the entire state of Nebraska via a hybrid delivery system. You choose the solution that is right for you - in person, online, or a combination of both! I WORK ON A SLIDING SCALE!! If you do not have insurance, ask me for more info!

One thought on “Informed Consent Document (Example)

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