Informed Consent For Psychotherapy Services

Last updated: January 1, 2022

Welcome to my Practice, Dr. C Therapist, PLLC. 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. “I”, “Us”, “We”, “Our”, “Ours” and other first-person pronouns will refer to the Practice, as well as all employees, contractors, and/or affiliates of the Practice. You, as the Client, may be referred to throughout this Agreement with second-person pronouns such as “You”, “Your”, “Yours.” By clicking on the checkbox on the appointment scheduling page you are agreeing that you have read, understood, and agreed to the content in this document, which will represent an agreement between you and my Practice. This informed consent may be amended at any time by reasonable notice, including without limitation by posting revised content on the Practice’s website at, which amended terms shall be binding upon you.

Psychotherapy Process. You have taken a courageous 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 some discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on feelings such as anger, sadness, or anxiety, amongst others.

On the other hand, psychotherapy may lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees as to what you will experience. 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 your repeating patterns, as well as to help you decipher what it is that you want for yourself and provide you with tools to help you regulate your emotions.

Psychotherapy Sessions. Normally all psychotherapy sessions are approximately 50 minutes each. However, the number and length of psychotherapy sessions may vary according to the treatment plan that best meets your needs.

You may schedule your psychotherapy sessions on our website,, or via phone, email, or text message. Fees vary according to the type of service recommended and will be agreed to when such service is requested. Fees are due at the time of service and may be paid via cash, Zelle, personal check, or credit card. If paying by credit card, for your convenience we will keep your credit card information on file with the Practice and charge you every time we complete a psychotherapy session.

Your appointment is a time commitment made to you and held exclusively for you. I do my very best to stay on schedule during the day, but there will be instances when I will be delayed in a session to care for a client in urgent need.

I have a fully booked Practice with many patients on a waiting list, so please CANCEL OR RESCHEDULE YOUR APPOINTMENTS AT LEAST 24 HOURS IN ADVANCE, or you will be charged the full fee for the missed appointment.

While health insurance is not accepted, a receipt may be provided to you, upon request, to submit to your insurance carrier for reimbursement for services from an out-of-network provider. Health insurance plans and benefits vary, so please consult your insurance provider about reimbursement for your psychotherapy services prior to your visit.

Telephone Accessibility: If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. If a true emergency situation arises, please call 911 or any local emergency room.

Psychotherapy Treatment Tools. The Practice may use different tools to support the psychotherapeutic process beyond the individual working sessions. Such tools may include neuroscience-based tools such as Safe and Sound Protocol (SSP), hypnosis, Eye Movement Desensitization and Reprocessing (EMDR), and HeartMath (“tools”). If I believe that any of these tools would be beneficial for your particular situation, I will discuss their advantages, limitations, and associated risks with you and let you decide if you want to proceed.

The use of one or more of these tools may augment the psychotherapeutic process significantly and bring about important and quick benefits for clients. If you decide to proceed, you knowingly and voluntarily accept, and assume responsibility for, each of the risks and dangers that could arise out of or occur during your participation in any treatment that involves the use of such tools.

Online Psychotherapy Sessions. Online psychotherapy, also known as e-therapy, teletherapy, and remote psychotherapy, is just like regular in-person psychotherapy. The only difference is, as the name suggests, we will work together online via Zoom, which is a HIPAA compliant video conferencing service, or over the phone. The same fee rates shall apply for teletherapy as it does for in-person psychotherapy.

Although there are benefits of remote psychotherapy, there are some differences between in-person psychotherapy, as well as some risks such as risks to confidentiality, issues related to technology, handling of emergencies, and overall efficacy. I would be happy to discuss this in more detail during our initial consultation. Online psychotherapy sessions may only be provided during the Practice’s normal business hours.

Assignment of Other Therapists. Depending on your specific psychotherapy treatment plan, we may introduce additional services and/or sessions to help you reach your mental health goals. These services and/or sessions may be provided by assigned qualified Practice employees and/or contractors. By entering this Agreement, you agree to such assignments, which I will discuss with you prior to proceeding.

Confidentiality. Except for certain specific situations described below, you have the absolute right to the confidentiality of your psychotherapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with my Practice without your prior written permission or unless mandated by law.

There are some situations in which I am legally obligated to take action to protect you or others from harm, even if I must reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused or has been abused, I may be required to make a report to the appropriate State agency.

If I believe that a client is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If a similar situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action.

When providing psychotherapy services to minors, I am committed to full confidentiality for children in order to provide the most therapeutic experience for them. However, I will provide generalized information about the therapy sessions to the parents/guardians, as I feel necessary and helpful. It is my policy to provide parents/guardians with general information about the minor’s treatment, but not to share specific information the minor has disclosed to me without his/her agreement. This includes activities and behavior that parents/guardians would not approve of — or might be upset by — but that do not put the minor at risk of serious and immediate harm. However, if the minor’s risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether the minor is in serious and immediate danger of harm, in which case I will communicate this information to the parents/guardians.

Occasionally I may need to consult with other professionals in their areas of expertise to provide the best treatment for you. Information about you may be shared in this context without using your name or any information that may identify you.

In most legal proceedings, you have the right to prevent me from providing any information about your psychotherapy treatment. In some legal proceedings, however, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order.

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Finally, if you elect to communicate with the Practice by email or cellular text message (SMS), please be aware that email and text messages are not secure, and confidentiality cannot be assured. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and I request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Legal Proceedings. I will not voluntarily agree to be part of any legal process with which you may be or become involved, including but not limited to divorce, child custody issues, or disability determinations. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.

Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s).

Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to pay, in advance, a retainer fee of $1,000 and to reimburse me at the rate of $500 per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.

Termination of Psychotherapy/Complaints. Psychotherapy involves a large commitment of time, money, and energy for both the Client and the Practice. Normally you will decide when to pause or end your psychotherapy work. However, the Practice may unilaterally decide to terminate the psychotherapy treatment if that is in the best interest of the Practice and/or the Client. In such situations, if requested the Practice may offer referrals to other sources of psychotherapy but cannot guarantee that they will be available.

If you ever feel that you are not satisfied with the psychotherapy services provided by my Practice, please talk to me about it so that I can respond to your concerns. I will take such feedback seriously, and with care and respect.

You agree that any controversy or claim for damages arising out of or relating to my Practice’s psychotherapy services shall be settled by arbitration administered by the American Arbitration Association in accordance with its Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. You agree that any claims for damages will be limited to the total fees paid by you during the psychotherapy process. In any such proceeding, if I am the prevailing party, you agree to an award for attorney’s fees and costs for such sum that the Arbitrator deems appropriate.