Example Informed Consent Document

This form is called a Consent for Services (the "Consent"). Your therapist, Robert Rust, ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.

HOW IT WORKS:

Robert Rust, MA, MFTI is a therapist operating under the supervision of Emily Eisenhart, LMFT, LPC. He earned his masters degree in May 2022 and is working through his two-year residency until he is licensed to operate without a supervisor in 2024. The Provider must meet with his supervisor to review cases. Supervision, in part, provides an opportunity for quality control while also maximizing effectiveness. Supervision requires disclosing limited client demographical information while also maintaining the highest degree of anonymity possible. For example, the supervisor will not know the client's name but may know their stage of life or general situation.

CONFIDENTIALITY

Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care, such as a supervisor.
• Your Provider may speak to emergency personnel.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

BENEFITS AND RISKS:

The counseling process is designed to be a time of healing and growth; healing may look different for each person and during each phase of the process. Learning to resolve difficulties in your life and relationships is a lifelong benefit of therapy. The goal is to help you develop and maintain healthy relationships and find fulfillment. The Provider can include and integrate spirituality in the counseling process to the degree that you are comfortable. Since the therapeutic experience is unique to each client, you may discover additional benefits as you work at resolving your specific concerns. While the hope is that you will benefit from therapy, outcomes cannot be guaranteed. 

ASSESSMENT:

at times during the counseling process, the Provider may recommend you complete an assessment. Before administering any assessment, the Provider will explain, to your satisfaction, the nature of the suggested assessment, offer instructions to complete the assessment, and answer questions you may have regarding the process. You have rights related to taking assessments. 1) You have the right to ask about or decline to participate in the assessment. 2) You have the right to an explanation of any assessment. 3) You have the right to a summary (which may be either verbal or written) of any assessment results.

FEES AND PAYMENT FOR SERVICES

You are required to pay for services. You will be provided with these costs prior to beginning therapy. You should also know about the following:
• No-Show and Late Cancellation Fees
• If you are unable to attend therapy, you must contact your Provider before your session. Otherwise, you may subject to fees outlined in your fee agreement.
• Balance Accrual
• Full payment is due at the time of your session. Any balance due will continue to be due until paid in full.
• Administrative Fees
• Your Provider charges administrative fees for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

RECORD KEEPING

Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.

COMMUNICATION

You decide how to communicate with your Provider outside of your sessions. You have several options: 
• Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
• Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you.
• Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

COMPLAINTS

If you feel your Provider has engaged in improper or unethical behavior, you can talk to them or their supervisor, or you may contact the licensing board that issued your Provider's license, or the US Department of Health and Human Services.