IntroductionTherapy is a process whichallows a person to work through problems or difficulties, and develop a happiermore fulfilling life. Therapy can be challenging and uncomfortable at times aspast trauma may be investigated, or unhealthy habits and beliefs challenged.However, the rewards can be life changing. An important part of this process isa clear understanding of client and therapist responsibilities and rights.
Please take the time to read this informed consent thoroughly and ask your therapistabout any questions you may have. Information AboutYour Therapist Name: ___Jessy Coulter_____________ IMF __MF12345_______ Name License / Registration # Therapist Status: Marriage and Family Therapist Intern*A status of MFT Intern signifies your therapist iscurrently completing their Master’s degree and pursuing licensure in theirstate. Your therapist’s supervisor is: _____James Brown____________License #: _MFC67890_________Contact Phone# (555) 323-4444 Information AboutThis PracticeName of Practice: “JBCounseling Centers, Inc.” The owner of JB Counseling Centers, Inc is:James Brown, LMFT, License #67890 Fees and InsuranceIndividual therapy session fee:$ ___100_______Joint (marital/family)therapy session fee: $ ___100_______ Group therapy session fee $____75______ ** Fees are payable at the time of service** Individual/Joint sessionsare approximately 50 minutes in length. Insurance Policy:JB Counseling Centers doesnot guarantee coverage of services by your insurance provider. Clients will beconsidered “Cash Pay” clients can verify that their insurance provider willcover their chosen service from JB Counseling Centers, Inc. Once coverage canbe verified with the client(s) and their therapist, an insurance paymentagreement can be created.
This agreement will include specifying what servicesare covered, and the deductible, co-payment, and re-imbursement specified by yourinsurance. This information will be provided by the client and their insurance.JB Counseling Centers, Inc does not guarantee coverage or payment by anyinsurance.
If insurance denies payment of services for any reason, the clientwill be held responsible for services provided. 48-Hour Cancellation Policy: If a client needs to cancelor reschedule an appointment, this must be done at least 48-hours prior to theappointment or the client will be responsible for the cost of the appointment.Insurance companies will not be billed for cancelled/rescheduled appointmentsthat do not meet the 48-hour policy. Inability to Pay:If a client findsthemselves unable to pay for services at any time, JB Counseling Centers asksthat the client informs our offices or your therapist as soon as possible.
Yourtherapist may be able to provide options for alternative services available. ConfidentialityAll clients have anabsolute right to the expectation of privacy and confidentiality regarding whatis discussed in their session. JB Counseling Services, Inc operates under theconfidentiality rules and regulations of the California Association of Marriageand Family Therapists (CAMFT) as well as the Health Insurance Portability andAccountability Act of 1996 (HIPAA). These rules and regulations apply to allcommunications, including hand-written, electronic, and verbal. Confidentialitymay only be broken with a specific written release of information signed by theclient.
There are specific exceptions to client/therapist confidentiality,which are listed below: SuspectedChild, Elder, or Dependent Adult Abuse:Your therapist is classified as a “Mandated Reporter”. This means that if theysuspect abuse has occurred to a child, elderly person, or dependent adult, theyare required by law to inform the appropriate government agency or protectiveauthority. The American Psychological Association defines abuse as any recentact or failure to act on the part of a parent or caretaker, which results indeath, serious physical or emotional harm, sexual abuse or exploitation, or anact 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 imminentdanger of a client harming themselves or others, they are required to informthe local police authority and/or crisis team, and/or attempt to inform theperson in danger. If possible, the therapist will try to explore options andspeak to the client before such action is taken. The safety of the client andothers are of upmost importance to JB Counseling Centers, Inc. Trainee/Supervisor Confidentiality: If your therapist has a status of a “trainee”, theymay at times need to share information about your case in order to gainappropriate guidance when necessary. The client may discuss this further withtheir therapist, and may ask questions to clarify what may be discussed.
Therapists will disclose only the information necessary to gain insight orguidance from their supervisor so that they may better support their client. Minors and ConfidentialityMinors (under the age of18) have the right to confidentiality as well in their communications withtheir therapist. However, parents andother guardians who provide authorization for their child’s treatment are ofteninvolved in their treatment. Consequently, your therapist, in the exercise of his or her professionaljudgment, may discuss the treatment progress of a minor patient with the parentor caretaker.
Clients who are minors andtheir parents are urged to discuss any questions or concerns that they have onthis topic with their therapist. Termination of TherapyThe client has the right todiscontinue therapy at any time. This canoccur if you or your therapist determines that you are not benefiting fromtreatment, and either of you may elect to initiate a discussion of yourtreatment alternatives. A signature below states anagreement by the client they have fully read and understood this informed consent,and addressed any questions or concerns with their therapist or an authorized representativeof JB Counseling Centers, Inc.
_________________________ ___________ Signature of Client(s) DateSigned _________________________ ___________ Signature of Client(s) DateSigned Relationship to minor: ____________________________