Client consent form

COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.

CONFIDENTIALITY: All interactions with Counseling Services, including scheduling of or attendance at appointments, content of your sessions, progress in counseling, and your records are confidential.


  • If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety.
  • A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a therapist to testify in a court hearing.

APPOINTMENTS: Each therapy appointment is traditionally a 50‐minute hour, unless specially arranged by the therapist. Once an appointment is scheduled, it is your responsibility to keep track of the dates and times of your appointments. If you must cancel your appointment or need to reschedule, please phone the office at least 24 hours in advance of your scheduled appointment. A late cancellation fee of $125 will be billed to you for the time that was reserved for your appointment. We reserve the right to terminate treatment with a client for failure to show up at two or more appointments. In cases of emergencies and/or hospitalizations, please discuss concerns with your therapist, as reducing/waiving this fee is at the discretion of the individual therapist.

PROFESSIONAL FEES: The hourly fee is $150 for the initial session and $125 thereafter. We ask that your account be kept current and payments be made at the conclusion of each session.

INTERACTION WITH THE LEGAL SYSTEM: I understand that I will not involve or engage my therapist in any legal issues or litigation in which I am a party to at any time either during my counseling or after counseling terminates. This would include any interaction with the Court system, attorneys, Guardian ad Litems, psychological evaluators, alcohol and drug evaluators, or any other contact with the legal system. In the event that I wish to have a copy of my file, and I execute a proper release, my therapist will provide me with a copy of my record, and I will be responsible for charges in producing that record. If I believe it necessary to subpoena my/my child's therapist to testify at a deposition or a hearing, I would be responsible for his or her expert witness fees in the amount of $1,000.00 for one-half (1/2) day to be paid five (5) days in advance of any court appearance or deposition. Any additional time that my therapist spends over one-half (1/2) day would be billed at the rate of $125.00 per hour including travel time. I understand that if I subpoena my therapist, he or she may elect not to speak with my attorney, and a subpoena may result in my therapist withdrawing as my counselor.


I have read and discussed the above information with my therapist. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of the Counseling Services.