Informed Consent Document.
Sample Solution
Informed Consent Document - Mental Health Counseling Services
Introduction
This Informed Consent Document outlines the services offered by [Your Name/Practice Name] ("Counselor") and the rights and responsibilities of both the client ("you") and the counselor. Please read this document carefully and ask any questions you may have before signing.
Services Provided:
Individual therapy sessions focused on [List your areas of specialty, e.g., anxiety, depression, relationship issues].
Confidentiality:
All information shared during therapy sessions is considered confidential, protected by law. However, there are some exceptions:
- Suspected harm to yourself or others
- Court order
- Potential child abuse or neglect
Client Rights
- You have the right to ask questions and request clarification at any point.
- You have the right to choose or terminate therapy at any time.
- You have the right to access your therapy records upon written request.
Client Responsibilities
- You are responsible for attending scheduled appointments and arriving on time.
- You are responsible for providing accurate and complete information to the best of your ability.
- You are responsible for coming to sessions prepared to actively participate in therapy.
Fees and Payment
- Your session fee is [amount] per session. Payment is due at the time of service.
- You are responsible for verifying your insurance coverage and obtaining any necessary pre-authorization.
Cancellation Policy:
Cancellations with less than [number] business days' notice will be charged the full session fee.
Emergency Situations
If you are experiencing a mental health emergency, please call 911 or proceed to the nearest emergency room.
Contact Information
Counselor Name: [Your Name] Phone Number: [Your Phone Number] Email Address: [Your Email Address]
Agreement
By signing below, you acknowledge that you have read and understand this Informed Consent Document and agree to the terms outlined.
Client Signature: __________________________
Date: __________________________
Counselor Signature: __________________________
Date: __________________________
Additional Notes:
- You may want to consider including a section about the limitations of therapy and the potential risks involved.
- You can adapt this template to fit your specific practice and areas of expertise.
- It is recommended that you consult with an attorney to ensure your Informed Consent Document meets all legal requirements in your area.