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.