Therapy Consent Form

THERAPY CONSENT FORM

Parties and Identifying Information

Client Name:    Date of Birth:

Therapist / Practice Information

Therapist Name:    License or Credentials:

Recitals

WHEREAS, Therapist provides mental health evaluation, psychotherapy, counseling and related clinical services in accordance with applicable professional standards; and

WHEREAS, Client seeks to receive such services and wishes to document informed consent to treatment, financial responsibility, confidentiality expectations and terms of engagement;

NOW, THEREFORE, in consideration of the mutual covenants herein, the parties agree to the terms set forth in this Therapy Consent Form.

Scope of Work

The Therapist will provide professional mental health services tailored to the Client's needs including assessment, individual psychotherapy, treatment planning, and related therapeutic interventions. Services do not include emergency or inpatient care unless specifically arranged in writing.

Payment Terms

Client agrees to pay for services rendered by Therapist in accordance with the following terms.

Client acknowledges responsibility for timely payment. If a third party (insurance) is billed, Client remains responsible for non-covered services, co-payments, deductibles and any balance not paid by the insurer.

Term and Termination

This Agreement commences on Start Date: and continues until End Date: , unless earlier terminated as provided below.

Either party may terminate this Agreement by providing written notice to the other party at least days in advance. Therapist may terminate immediately for violations of safety, nonpayment, or behavior that materially impedes treatment.

Confidentiality and Limits

Communications between Client and Therapist are confidential and will not be disclosed without Client's written authorization, except where disclosure is required or permitted by law. Exceptions include, but are not limited to: (a) reasonable belief of imminent risk of serious harm to the Client or others (duty to warn/protect); (b) suspected child, dependent adult, or elder abuse; (c) court order or legal proceedings; (d) when Client requests release of information in writing; and (e) where billing or collection necessitates disclosure to third-party payers, to the extent required by that payer.

I authorize Therapist to disclose clinical information as reasonably necessary to process claims and obtain payment from my insurer or other payers. I understand that submission of claims may require disclosure of diagnosis, dates of service, treatment codes and a brief clinical summary.

Telehealth Consent

I consent to receiving mental health services via telehealth (telephonic or video) when agreed upon with Therapist. I understand risks specific to telehealth services, including technology failures, privacy limitations, and the possibility that telehealth may not be equivalent to in-person services.

I consent to telehealth services.    I do not consent to telehealth services.

Cancellation and No-Show Policy

Appointments canceled with less than hours' notice may be subject to a cancellation fee up to the full session rate. Repeated no-shows or late cancellations may result in termination of services.

Risks, Benefits, and Alternatives

Psychotherapy can have benefits and risks. Benefits may include reduced symptoms, improved functioning and coping. Risks may include uncomfortable emotions, changes in relationships, or uncovering painful memories. Alternatives to psychotherapy may include medication, group therapy, community supports, or no treatment. Client acknowledges having discussed these matters with Therapist and had opportunity to ask questions.

Governing Law

This Agreement will be governed by and construed in accordance with the laws of the state in which Therapist maintains the primary practice location, without regard to conflict-of-law principles.

Entire Agreement

This Consent Form, together with any written addenda signed by both parties, constitutes the entire agreement between Client and Therapist concerning the subject matter herein and supersedes all prior agreements or understandings, whether written or oral.

Acknowledgment and Consent

By signing below, Client acknowledges that they have read and understood the terms of this Therapy Consent Form, have had opportunity to ask questions, and consent to receive services under these terms. Client acknowledges receipt of information regarding confidentiality and limits to confidentiality and accepts financial responsibility as described.

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