Therapy is a process which
allows a person to work through problems or difficulties, and develop a happier
more fulfilling life. Therapy can be challenging and uncomfortable at times as
past trauma may be investigated, or unhealthy habits and beliefs challenged.
However, the rewards can be life changing. An important part of this process is
a clear understanding of client and therapist responsibilities and rights.
Please take the time to read this informed consent thoroughly and ask your therapist
about any questions you may have.
Name: ___Jessy Coulter_____________
Name License / Registration #
Marriage and Family Therapist Intern
*A status of MFT Intern signifies your therapist is
currently completing their Master’s degree and pursuing licensure in their
Your therapist’s supervisor is: _____James Brown____________
License #: _MFC67890_________
Contact Phone# (555) 323-4444
Name of Practice: “JB
Counseling Centers, Inc.”
The owner of JB Counseling Centers, Inc is:
James Brown, LMFT, License #67890
Fees and Insurance
Individual therapy session fee:
therapy session fee: $ ___100_______
Group therapy session fee $
** Fees are payable at the time of service**
are approximately 50 minutes in length.
JB Counseling Centers does
not guarantee coverage of services by your insurance provider. Clients will be
considered “Cash Pay” clients can verify that their insurance provider will
cover their chosen service from JB Counseling Centers, Inc. Once coverage can
be verified with the client(s) and their therapist, an insurance payment
agreement can be created. This agreement will include specifying what services
are covered, and the deductible, co-payment, and re-imbursement specified by your
insurance. This information will be provided by the client and their insurance.
JB Counseling Centers, Inc does not guarantee coverage or payment by any
insurance. If insurance denies payment of services for any reason, the client
will be held responsible for services provided.
48-Hour Cancellation Policy:
If a client needs to cancel
or reschedule an appointment, this must be done at least 48-hours prior to the
appointment or the client will be responsible for the cost of the appointment.
Insurance companies will not be billed for cancelled/rescheduled appointments
that do not meet the 48-hour policy.
Inability to Pay:
If a client finds
themselves unable to pay for services at any time, JB Counseling Centers asks
that the client informs our offices or your therapist as soon as possible. Your
therapist may be able to provide options for alternative services available.
All clients have an
absolute right to the expectation of privacy and confidentiality regarding what
is discussed in their session. JB Counseling Services, Inc operates under the
confidentiality rules and regulations of the California Association of Marriage
and Family Therapists (CAMFT) as well as the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). These rules and regulations apply to all
communications, including hand-written, electronic, and verbal. Confidentiality
may only be broken with a specific written release of information signed by the
client. There are specific exceptions to client/therapist confidentiality,
which are listed below:
Child, Elder, or Dependent Adult Abuse:
Your therapist is classified as a “Mandated Reporter”. This means that if they
suspect abuse has occurred to a child, elderly person, or dependent adult, they
are required by law to inform the appropriate government agency or protective
authority. The American Psychological Association defines abuse as any recent
act or failure to act on the part of a parent or caretaker, which results in
death, serious physical or emotional harm, sexual abuse or exploitation, or an
act or failure to act which presents an imminent risk of serious harm.
Imminent Risk to Self or Others: If your therapist determines there is an imminent
danger of a client harming themselves or others, they are required to inform
the local police authority and/or crisis team, and/or attempt to inform the
person in danger. If possible, the therapist will try to explore options and
speak to the client before such action is taken. The safety of the client and
others are of upmost importance to JB Counseling Centers, Inc.
Trainee/Supervisor Confidentiality: If your therapist has a status of a “trainee”, they
may at times need to share information about your case in order to gain
appropriate guidance when necessary. The client may discuss this further with
their therapist, and may ask questions to clarify what may be discussed.
Therapists will disclose only the information necessary to gain insight or
guidance from their supervisor so that they may better support their client.
Minors and Confidentiality
Minors (under the age of
18) have the right to confidentiality as well in their communications with
their therapist. However, parents and
other guardians who provide authorization for their child’s treatment are often
involved in their treatment.
Consequently, your therapist, in the exercise of his or her professional
judgment, may discuss the treatment progress of a minor patient with the parent
or caretaker. Clients who are minors and
their parents are urged to discuss any questions or concerns that they have on
this topic with their therapist.
Termination of Therapy
The client has the right to
discontinue therapy at any time. This can
occur if you or your therapist determines that you are not benefiting from
treatment, and either of you may elect to initiate a discussion of your
A signature below states an
agreement by the client they have fully read and understood this informed consent,
and addressed any questions or concerns with their therapist or an authorized representative
of JB Counseling Centers, Inc.
Signature of Client(s) Date
Signature of Client(s) Date
Relationship to minor: ____________________________