Informed Consent and Therapy Contract
It is important for you to be fully informed about the therapy services you will be receiving. Your signature below indicates you have received read, and understand the practice policies and are able to make an informed decision about entering therapy. It is also important you understand Kristy Norris, LMFT complies with HIPPA regulations regarding client confidentiality.
1. I understand my therapist is trained to provide therapy to individuals, couples, and families from a systems perspective utilizing therapeutic approaches/models associated with the marriage and family therapy profession.
2. I understand my therapist is bound by the Code of Ethics set forth by the American Association for Marriage and Family Therapy (AAMFT) and I may request a copy of those ethics at any time.
3. I understand, as a client, I have certain rights and those rights have been reviewed with me by my therapist.
4. I understand, except under specific circumstances mandated by law, communications with my therapist will remain confidential as well as any records regarding the therapy process unless I sign an Authorization & Request for Release of Confidential Information and Privileged Communication form. If more than one family member participates in a session, each and every participating family member must consent prior to the release of the file information. Where a minor is receiving services, the appointment of a guardian ad litem may be necessary prior to the release of the minor client's information The client's family members are not entitled access to client information just because they are family.
5. I understand specific circumstances require my therapist to break confidentiality and report information obtained asa result of the therapy process. Those circumstances exist when: a) a client may be a danger to him or herself orto others; b) a child, elderly or disabled person may be subject to abuse or neglect; c) when a court order exists, information regarding the therapy process will be provided.
6. I understand my therapist may be required to consult with my primary care physician or psychiatrist to determine if there may be a medical condition or medication that is contributing to symptoms of a mental disorder which may have been observed in therapy. In order to complete such a consultation, my therapist will request I complete a Release of Information form. The client/parent/legal guardian may choose to waive such consultation by discussing this in session with the therapist.
7. I understand there can be risks and benefits associated with therapy and have discussed those with my therapist.
8. I understand I may leave therapy at any time and agree to discuss the termination of therapy at a regular therapy session.
9. I understand the financial policies guiding my therapist's practice and agree to pay $150 for my sessions at the time of service, unless there is a special in which you have discussed with the therapist in advance.
10. I understand extra fees may apply if my therapist is required to be in court or court-related documentation of my case is required
11. I understand if there is no session activity or phone contact recorded in my file for a period of 4 weeks, my file will automatically be closed. I understand, in most circumstances, my file can be re-opened upon completion of a new intake and payment of any delinquent fees.
My Signature below indicates I give my full informed consent. All clients over the age of 10 must sign.