Form

Purpose of Agreement

This agreement outlines the terms and conditions for participation in a therapy intensive session provided by Choosing Change Counseling (“the Practice”). By signing this document, the client acknowledges understanding and agreement to the terms related to scheduling, payment, cancellations, and clinical expectations.

Nature of the Intensive

The therapy intensive is a customized, extended-format session designed to provide concentrated therapeutic work using Eye Movement Desensitization and Reprocessing (EMDR) and other evidence-based modalities. This intensive is not a substitute for regular, ongoing psychotherapy and should be integrated into a broader treatment plan, when applicable.

Fees and Payment

Rate: $250 per clinical hour

A 50% deposit is required to schedule your intensive. The remaining 50% balance is due no later than 48 hours prior to the scheduled start of the intensive.

If the client would like to extend the length of the intensive, this option is available at the discretion of the therapist and is contingent upon scheduling availability. Additional intensives may be scheduled if it is not available and is deemed appropriate by the therapist.

Payment Methods Accepted: Credit Card, Cash, Check, FSA/ HSA, and Venmo.

Cancellation and Refund Policy

Cancellations must be submitted in writing via email to: Miriah@ChoosingChangeCounseling.com.

• A 50% deposit is required to reserve your intensive session.
• The deposit is 100% refundable if canceled 7 or more days before the scheduled session.
• The deposit is 50% refundable if canceled between 72 hours (3 days) and 6 days before the session.
• The deposit is non-refundable if canceled less than 72 hours before the scheduled session.
• Emergency reschedules may be permitted for verified illness, personal emergencies, or other unforeseeable circumstances at the discretion of the therapist.
• If the therapist must cancel or reschedule for any reason (e.g., illness or emergency), the client may choose between a full refund or rescheduling the session without penalty.

Scope of Services and Results Disclaimer
 

• The therapist will provide care within the scope of their licensure and training, using clinical judgment to tailor the intensive to the client’s needs.
• While EMDR and intensive therapy are evidence-based and widely supported by research, the therapist makes no guarantees regarding outcomes.
• Every individual’s progress depends on multiple factors, including history, readiness, and post-session integration.

Voluntary Participation and Acknowledgment of Emotional Risk

• The client understands that intensive therapy can evoke strong emotional reactions, resurfacing of past traumatic material, and emotional discomfort both during and after the session. Delayed emotional responses or physiological reactions (e.g., fatigue, tearfulness, agitation, vivid dreams, found memories) are also common and expected as part of the therapeutic process.
• The client acknowledges that these responses are a normal part of trauma resolution and agrees to participate voluntarily with this understanding.
• The client is encouraged to openly communicate with the therapist at any point if distress becomes unmanageable or if additional support is needed during the session.
• The client understands that while safety and regulation techniques will be incorporated into the intensive, the therapist cannot fully predict or prevent all emotional reactions.
• The client is responsible for engaging in appropriate aftercare and integration activities as discussed with the therapist. This may include rest, journaling, grounding practices, or follow-up sessions as clinically indicated.

Emergency and Crisis Support

Choosing Change Counseling does not provide crisis services or 24-hour support. If the client experiences a mental health emergency, they agree to contact 911 or go to the nearest emergency room.

The therapist will prioritize communications with the intensive client for 72 hours following the conclusion of the intensive to support post-session stabilization and integration.

Termination of Services

The therapist reserves the right to terminate the session or refuse service if:

• The client arrives under the influence of alcohol or substances.
• The client is verbally or physically aggressive.
• It is determined that the intensive is no longer clinically appropriate or in the best interest of the client. Written rationale will be provided if this is deemed necessary.

Consent to Treatment

By signing below, I acknowledge:

• I have read, understood, and agreed to the terms in this contract
• I understand the fee, refund policy, and nature of the intensive
• I understand the potential risks of EMDR and therapy intensives
• I consent to participate in treatment under these terms