Informed Consent for Counseling

INFORMED CONSENT FOR COUNSELING

Please read the following and then sign to indicate agreement:

In an effort to promote a trusted and productive counseling relationship, the following is provided for your understanding and signed consent.

COUNSELING: The goal for counseling is positive change. Many people come to counseling because they are ready to make significant changes in their lives. They want to work with a professional who can help them explore options for change in a comfortable, safe, place outside of their daily lives. Counseling can be seen as a process or a vehicle to assist them to make changes more thoughtfully and/or more rapidly. Others may enter counseling because change has been thrust upon them, and they want a healthy, thoughtful way to begin the rebuilding process.

There are no guarantees that counseling is going to “fix” the problem. Counseling is most effective when it is a collaboration between you and your therapist. We will provide you with the absolute highest level of professional care that we can. Your therapist may suggest outside reading or activities and may provide “homework” assignments. If necessary, your therapist may recommend that you consult with a physician to receive medication therapy or other medical treatment.

While in counseling, you are responsible for being as honest and open as possible. Change usually involves letting go of things or ideas that are familiar in order that new possibilities can emerge. Effort and risk will be required. There may be some emotional pain. You may experience embarrassment, anxiety, frustration, or fear. On the other side of these uncomfortable emotions is healing and growth.

LICENSING AND EITHICAL INFORMATION: Positive Steps Counseling only employs licensed mental health counselors and state-approved registered therapist interns. Any complaint or questions about our counseling services that cannot be resolved between us should be directed to the State of Florida Department of Health.

CONFIDENTIALITY: As a routine matter, information disclosed by you and/or your child during therapy will be kept strictly confidential and will not be revealed to anyone outside of Positive Steps Counseling without your permission. It is important for you to know that there are some exceptions to confidentiality. If an exception should arise, we will make every effort to inform you.

Exceptions to Confidentiality:

1) If you threaten to harm yourself or another person, we are legally, ethically and morally required to take action to protect the safety of the threatened person. Actions could include: Informing the intended victim, arranging for hospitalization for you and/or your child, notifying family or support systems, or alerting law enforcement.

2) If abuse or neglect of a child, aged or disabled person is known or suspected, we are required by Florida law to report our concerns to the Department of Children and Families.

3) If we were to receive a legally binding Court Order from a Judge for your counseling records or for our deposition or court testimony, we would be required by law to comply.

4) If you or your child are in counseling or are being evaluated by Order of the Court or as condition of continued employment, we may be required to provide the Court or the Employer with reports, documents, or testimony.

EMERGENCIES OR CRISES: Positive Steps Counseling checks email and voicemail every day, including weekends and holidays. We will return your call at our earliest opportunity. If you are unable to reach us, or if you have a life-threatening emergency, immediately call 911, or go to a hospital emergency room. Your safety and well-being is our primary concern.

CONSENT FOR COUNSELING: I have read and understand the information contained on this form and voluntarily agree to participate in counseling and/or consent to the participation of my child in counseling.

Printed Name (first and last)

Adult Client Signature (if counseling is for a family)

Adult Client Signature (if counseling is for a family)