Informed Consent for Mental Health Counseling

Introduction

This document is designed to inform you of your rights and responsibilities as a client in counseling, as well as the policies and practices of this office. Please read it carefully and feel free to ask any questions before signing. Your signature indicates that you understand and agree to participate in counseling services.

---

Nature and Purpose of Counseling

Counseling is a collaborative process between you and your counselor, intended to help you achieve goals such as improving emotional well-being, managing stress, enhancing relationships, and addressing mental health concerns. Counseling may include discussion of personal events, feelings, behaviors, and relationships. The outcome cannot be guaranteed, but clients generally benefit from increased insight and coping skills.

---

Risks and Benefits

• Benefits: Increased self-awareness, improved relationships, symptom relief, healthier coping strategies.
• Risks: You may experience uncomfortable emotions (such as sadness, anger, or anxiety), temporary distress, or conflict in relationships as part of the healing process.

---

Confidentiality

Your privacy is protected under Florida law and the Health Insurance Portability and Accountability Act (HIPAA). Information disclosed in counseling sessions is confidential, with the following exceptions:

1. If you pose an imminent risk of harm to yourself or others.
2. If there is suspected abuse or neglect of a child, elder, or vulnerable adult.
3. If records are subpoenaed or otherwise required by law.
4. If you provide written authorization for release of information.

---

Professional Records

Counselors maintain clinical records of your sessions, which you have the right to review. Records are stored securely and released only with your written consent or as required by law. Any therapeutic notes taken regarding my situation will be held in strictest of confidences.  I understand that even if I waive confidentiality, therapy notes will not be provided to anyone, for any reason, unless there is a court order issued by a Judge. 

---

Fees and Payment

• Standard session fees will be billed to my insurance or EAP. 
• Self-Pay fees will be billed, based on the clinician providing the services. 
• Payment is due at the time of service unless prior arrangements are made.
• Missed appointments not canceled with at least 24 hours’ notice may result in a late-cancellation fee of $95.00. I understand insurance does not cover this fee and I will be responsible for the fee. I will not initiate any charge backs with my bank, as I have been informed and notified in advance. 

---

Insurance

If you choose to use insurance, your information will be shared with your insurance company as needed for reimbursement. Please note that insurance may limit the number of sessions, require a mental health diagnosis, or deny coverage. You are responsible for all fees not covered by insurance. You are responsible for knowing and understanding your healthcare benefits.

---

Client Rights

As a client, you have the right to:

• Be treated with dignity and respect.
• Participate actively in setting goals for counseling.
• Request a referral to another provider at any time.
• Refuse or discontinue treatment, understanding the potential risks.
• Receive services regardless of race, ethnicity, gender, religion, age, disability, or sexual orientation.

---

Telehealth Services

Telehealth counseling may be offered via secure video platform. The same confidentiality and professional standards apply. You are responsible for ensuring privacy at your location and stable internet access.

---

Emergencies

This office does not provide 24-hour crisis services. In case of an emergency, please call 911 or go to your nearest emergency room. You may also call the National Suicide Prevention Lifeline at 988.

---

Additional Items

I am aware that animals may be used for therapeutic purposes at this office and I give my consent for an animal to be near me.  If this does not apply to me, I will discuss it with office staff.

I understand that there are cameras monitoring the office lobby and hallway, both audio and video.  This is the safety and well-being of all who enter the office. 

I am aware that I may receive a mental health diagnosis, in accordance with the current edition of the Diagnostic and Statistical Manual of Mental Disorders.  

The use of a virtual scribe may be used: and it generates necessary documentation for the clinician. This eliminates the need for manual notetaking, and ensures that the time with your clinician flows smoothly and without interruption. 

The documents produced by the scribe are derived from session recordings, which are not stored and are automatically deleted after processing. The scribe complies with HIPAA regulations, with all data encrypted both in transit and at rest.

---

Consent

By signing below, you acknowledge that you have read and understood the information in this document, and that you consent to participate in counseling under these terms.