Professional Counseling Informed Consent Form

Professional Counseling Informed Consent Form
Comp Serv Health Resources International Wellness City

We are a licensed counseling clinic with several years of experience specializing in various counseling. We value our relationship with our clients and believe that such relationship is the beacon in the healing process.

We believe that each individual is unique and has his own way of addressing resolutions. Thus, we believe in a wellness model that helps our clients empower themselves by focusing on what works for them and not in a systematic approach that provides a generic procedure on working on a treatment. One's journey is not the same as the other.
Client's Rights
1. The client may ask questions on what to expect during and end result of the therapy.
2. The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist.
3. The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.
4. The therapist has the right to dismiss the client from the course of therapy.
5. The client has the right to review his or her records from the therapist.
6. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client.
7. The client can raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client.
Please check the items that you believe is affecting you

Alcohol or drug problemsAnger or hostile feelingsAnxiety, nervousness, fearsSadness or DepressionEating or appetite problemsFamily issuesProcrastinationPhysical distressRelationship/marital concernsSexual concernsShynessTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStressSleep disorderSelf-controlSelf-esteem or confidenceWork or career concerns
Acknowledgement

I have reviewed this Professional Counseling Informed Consent Agreement. I likewise understand my Client's Rights set in this form.

I accept this agreement and consent to counseling.
Client Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Signature

Clear
Social Social Security Number
Date Signed

MonthDayYear
Date
Birth Date

MonthDayYear
Insurance

Medicaid MolinaMedicaid Well CareMedicaid AetnaMedicaid AnthemPrivate InsuranceMedicaid HumanaNC Medicaid Healthy BlueOther
Should be Empty: