Adult Consent Form

Name *

First Name Last Name

I understand that I will be engaging in psychotherapy at In One Peace Counseling Services. My therapist will be: *

*

The purpose of this treatment is so that I feel better or resolve specific life or adjustment problems that have caused me to seek assistance. The primary procedure used by my therapist is “talk” therapy. She utilizes a variety of techniques which are likely to include any of the following: dialogue, interpretation, cognitive reframing, awareness exercises, self-monitoring experiments, visualization, journaling, drawing, or reading assigned books. She may recommend that I consult additionally with a physician or non-traditional (homeopathic and Oriental medicine) practitioners. The potential benefit of treatment is that I will feel better about my life and experience a significant reduction in feelings of distress while improving relationships and the quality of my life. I understand that a “cure” is not guaranteed and that it is possible that as I work on some things, I may experience uncomfortable feelings like sadness, loneliness, and/or recalling parts of my personal history that I find unpleasant. I understand that all information I share will be kept confidential, but that this confidentiality is not absolute. In the case of medical emergency, child/elder abuse or neglect, suicidal or homicidal intent, or under court order, clinical information may be released. I also understand that if I elect to have my treatment paid for by an insurance company, my therapist may provide my insurance company with otherwise confidential information to support billing.

I understand the therapist I will see, is: *

an independently licensed professional counselor, social worker, or marriage and family therapist, and as such is not obligated to receive clinical supervision. However, in an effort to provide services that reflect best practices, my therapist may regularly meet in a peer consultation group in which cases are discussed and additionally may consult with an identified Clinical Consultant. I understand that if my case is discussed in the peer consultation group or with the Clinical Consultant I will not be identified by name. Should the Clinical Consultant review records containing Protected Health Information the Consultant will be bound by the same rules about confidentiality as is my therapist. licensed at the associate level as a professional counselor or social worker and receives regular clinical supervision from a team of independently licensed clinicians. The clinical supervisor of that team is Dr. Jessica Dorland LPC who can be reached at (520) 302-4116.

*

I understand that I can receive a copy of my records or have a copy of my records provided to another person by completing a Release of Information form and that a session fee may be charged for this service. I understand that I have the right to participate in treatment decisions and that my therapist and I will together develop and periodically review and revise a treatment plan which will identify my goals for treatment as well as the means of achieving those goals. I understand that I have the right to refuse any recommended treatment and that I may withdraw my consent to treatment at any time with no consequences. I understand that the fee for a session is $150. If I my treatment is paid for by my insurance company, I understand that I am responsible for my co-pay. In addition, should my insurance company not cover my treatment, I understand that I am responsible for the full session fee. A receipt or statement will be provided to me upon request. I understand that a reduced fee may be negotiated for me if treatment is otherwise not affordable. I understand that additional fees may occur in instances of preparation of letters or documents, home visits, phone calls lasting longer than 7 minutes, attendance to meetings, consultations, etc. I understand that a $30 fee will be assessed for any check returned for Non-Sufficient Funds. 24-hour notice is required in instances of cancellation or change in appointment. Late cancellations or No-Show will incur a fee of $50 although my therapist may waive this fee at her discretion.

I have read the above information and consent for treatment.

Signature *

Clear