Consent For Treatment

Consent For Treatment


Welcome to The Counseling Center. Thank you for choosing us as your mental health care professionals. This document contains important information about our professional services and business policies. In addition, it explains some basic principles that will enhance the therapeutic process. Please read it carefully and jot down any questions you might have so that you can discuss them during your initial meeting with your therapist. Our mutual understanding and adherence to these ground rules and administrative policies will aid in the most effective use of our time and efforts. It may also minimize the possibility of future misunderstandings that might interfere with the therapeutic process. When you sign this document, it will represent an agreement between us.

General Information

The therapeutic relationship is unique in that it is highly personal, and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of 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 counseling. 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.


All aspects of your treatment are confidential. I will need your written permission if you wish me to discuss your treatment with anyone else. Without your written permission, I cannot reveal any information about you or your treatment. Even the fact that you are a client in our practice is protected by confidentiality.

Exceptions to Confidentiality

  1. If I believe, in my professional opinion, that you are an imminent danger to yourself or to someone else, then I must attempt to ensure the physical safety of those involved, even if this means breaking confidentiality.
  2. If you give me information pertaining to the abuse or neglect of a child, an elderly person, or a disabled person, past or present, and the victim is identified, I am required to report this information to the local authorities, even without your permission. I am required to report even a suspicion of such abuse to the local authorities.
  3. I may also be required to discuss aspects of your treatment without your permission if I am subpoenaed or court-ordered to do so. These situations rarely occur. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.

Contacting Your Provider

Providers are not often immediately available by telephone. Email is the quickest way to reach your provider. If you would like to speak on the phone, you may leave a message on our confidential voicemail. We will make every effort to return your call within 24 hours, except for weekends and holidays. Messages left on weekends and holidays will be returned the next business day.


In the event of a psychiatric emergency, please call 911 or go to the nearest emergency room and ask to be evaluated by a mental health practitioner. The National Suicide Prevention Lifeline is also available 24 hours a day, 7 days a week at (800) 273-TALK (1-800-273-8255).

Therapeutic Relationship

I will use my best knowledge and skills to help you. This includes following the standards of the American Counseling Association (ACA). In your best interests, the ACA puts limits on the relationship between a therapist and a client, and I will abide by these. Let me explain these limits, so you will not think they are personal responses to you. If we meet on the street or socially, I may not say “hello” or talk to you very much. My behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship. I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend, or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during or after the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship.

I do not discriminate against clients because of age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, personal identity, sexual orientation, gender identity, or criminal record (unrelated to present dangerousness). I will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity.

Our Agreement

My signature below indicates that I have read and discussed this agreement. I understand that after therapy begins, I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with my therapist before terminating treatment. I have read, or have had read to me, the information contained in this notice, which is also available on The Counseling Center’s website at I have discussed the points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this notice. I hereby agree to begin therapy with The Counseling Center, LLC, and to cooperate fully and to the best of my ability, as evidenced by my electronic signature below.


Effective Date:  June 30, 2019

Last Revised:  December 12, 2020

Last Reviewed:  December 12, 2020

Next Review:   December 12, 2021

Approved By: Jason Lynch, Owner/CEO