Informed Consent for Psychotherapy

General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Counseling/Therapy outcomes. No one can guarantee that counseling/therapy will produce certain results. There are some risks associated with counseling. For example, you may discover things about yourself that are uncomfortable;sometimes relationships change as a result of counseling; if you are discussing

a traumatic event with your counselor, sometimes the feelings get more intense. We can assure you that your counselor will use his or her professional skills to the best of his or her ability to address your concerns and help manage possible risks.

Also, please be aware of the following conditions in regard to discontinuing counseling/therapy:

1.      If your counselor/therapist believes that he or she is not able to help you, because of the kind of problem

you have or because his or her training and skills are not appropriate, you will inform you of this fact and refer you to another therapist who may meet your needs.

2.      If you have two “no-shows” or same-day cancellations for appointments.

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3.      If you have not had and kept an appointment in our office in 6 consecutive weeks and this is not part of your treatment plan.

4.      If you commit and act of violence toward, threaten, or harass any staff member or client of Knight Counseling and Consultation Solutions LLC, you will be immediately terminated from treatment.


5.      If you are terminated from counseling/therapy for something other than completing the agreed-upon

treatment plan, you will be given contact information for other sources of counseling/therapy. However, Knight Counseling and Consultation Solutions LLC cannot guarantee that they will accept you for counseling/therapy.

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

  1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

  2. If a client threatens grave bodily harm or death to another person.

  3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

  4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

  5. Suspected neglect of the parties named in items #3 and # 4.

  6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

  7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

***Supervision and Consultation. ***Counselors work to improve their practice and skills through consultation with other
colleagues. In the event the counselor is consulting about your case with other qualified professionals, your full name will not be disclosed, but it’s possible elements of your case will be discussed in order to provide clients
with the best possible care.

Communications Policy

Contacting Me

When you need to contact your therapist for any reason, these are the most effective ways to get in touch
in a reasonable amount of time:

  • By phone (304-539-0342.)
    You may leave messages on the voicemail, which is confidential.

  • By secure text
    message (see below for details.)

Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I am not prepared to watch them closely for important
messages from clients. It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.

Response Time

I may not be able to respond to your messages and calls immediately. For voicemails and other messages, you can expect a response within 24 hours (weekends by Tuesday) I may occasionally reply more quickly than that or on
weekends, but please be aware that this will not always be possible.

Be aware that there may be times when I am unable to receive or respond to messages, such as when out of cellular range or out of town.

Emergency Contact

If you are ever experiencing an emergency, including a mental
health crisis, please call * Highland Hospital
at  304-326-1600 or The Suicide Hotline
at 800-273-8255*

If you need to contact me about an emergency, the best
method is:

  • By phone

  • If you cannot
    reach me by phone, please leave a voicemail and then follow up with a
    secure text message.

Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole
method of communicating with me in emergencies.

Disclosure Regarding Third-Party Access to Communications

Please know that if we use electronic communications methods, such as email, texting, online video, and possibly others, there are various technicians and administrators who maintain these services and may have
access to the content of those communications. In some cases, these accesses
are more likely than in others.

Of special consideration are work email addresses. If you use your work email to communicate with me, your employer may access our email communications. There may be similar issues involved in school email or other
email accounts associated with organizations that you are affiliated with. Additionally,
people with access to your computer, mobile phone, and/or other devices may
also have access to your email and/or text messages. Please take a moment to
contemplate the risks involved if any of these persons were to access the
messages we exchange with each other.

***Access to records. ***Generally speaking, you have access to your mental health record. You should also understand that
psychotherapy notes may not be part of your mental health record. There are certain, limited, and rare situations wherein your counselor/therapist may deny you access to psychotherapy notes to reduce the risk of harm to you or someone else.

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Billing.** **All bills, including copayments, will be paid at the time of service. By signing, you are agreeing to authorize payments of any insurance benefits directly to Knight Counseling and Consultation Solutions LLC. Sometimes,
when payments are not made and are delinquent beyond 30 days Knight Counseling and Consultation Solutions LLC
 may use a collection agency to assist with collecting delinquent fees. If we need to use a collection agency to collect
unpaid fees, the client may be responsible for any collection fee charged to collect the debt owed.

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Missed appointment policy.** ** By signing below, you understand that you will be charged a $35.00 fee for missed appointments or cancellations when they are not cancelled at least 24 hours in advance.  In addition, you may not be rescheduled if you miss consecutive appointments without notifying Knight Counseling and Consultation Solutions LLC in advance.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it’s appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

​© 2015 by Knight Counseling and Consultation Solutions LLC.

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