IMPORTANT INFORMATION AND CLIENT CONSENT: Please read and sign at the end stating you have fully read and understand the information below.
CLIENT/THERAPIST RELATIONSHIP: You and your therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect.
RISKS AND BENEFITS: Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. However, the benefits of counseling can far outweigh any discomfort encountered during the process. Some of the possible benefits are improved personal relationships, reduced feelings of emotional distress, and specific problem solving.
*I have been advised and understand that a component of the treatment I receive may utilize a technique called energy checking and involves work with energy treatment points. Energy checking is an assessment tool for determining how energy patterns may be related to the problems you wish to address. This technique involves my psychotherapist applying physical pressure on my arm, that will determine if a specific muscle stays firm or loses strength when focusing on a particular thought, emotion or problem state. The information from the muscle test may indicate emotional dimensions that may not be available through introspection. Based partially on this information, my therapist will advise me on which energy points may best be used in helping me achieve my goals. You can choose an alternate approach if you choose.
Energy treatment points, adapted from the practice of acupressure, are located on the surface of the skin throughout the body and can be stimulated for the purpose of correcting disturbed energy patterns that might underlie emotional and psychological problems.
Stimulation may include tapping, rubbing, or touching the points, usually on the face, sternum, hands, etc. I will be instructed on how to stimulate the appropriate points myself.
I understand that the use of energy checking and energy treatment points within the field of psychotherapy is a new development and that at this time there is very little published research in established scientific journals investigating these methods. While clinical reports of successful outcomes using these methods do exist in the published literature of the field known as energy psychology, (150 clinical studies), and the methods are being developed and refined under the auspices of organizations such as the Association for Comprehensive Energy Psychology, I understand that clinical reports do not constitute conclusive scientific evidence. I further understand that even if the clinical effectiveness of these methods is scientifically established, results will vary from person to person.
Reactions may surface during a treatment that neither my therapist nor I can fully anticipate, which may include strong emotional or physical symptoms or bring memories of additional, unresolved memories.
Emotional material may continue to surface after a treatment session and give indication of other incidents that may need to be addressed.
Previously vivid or traumatic memories may fade. This could adversely impact the ability to provide legal testimony regarding a traumatic incident.
I will be learning personal self-care with my own energy system as part of the therapeutic process.
My practitioner may refer me to other practitioners who have specific skills to help with problem areas beyond scope of practice.
I have thoroughly considered all of the above and have obtained whatever additional input and/or professional advice I deemed necessary or appropriate about commencing treatment that utilizes energy checking and energy treatment points.
I know I have the right to cease using this approach or deny any physical contact at any time.
By my signature below, given freely and without pressure or influence from any person, I consent to the use of these methods in my treatment plan.
Suggestions may be as optional interventions, however should not be taken as Medical Advice.
I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.*
APPOINTMENTS: Every attempt will be made to schedule appointments at times convenient to you and are approximately 55 minutes long. In cases, other than an emergency, A 24 HOUR CANCELLATION NOTICE is required for appointments you are unable to keep. Failure to honor this notification will result in a charge of $60 payable prior to scheduling the next session. You can reach me via phone: 317-691-7645 or by email: firstname.lastname@example.org or email@example.com about your appointment.
When I am not in the office, I check my messages and I will return your call within 24 hours.
Individual therapy rates apply, whether in person or tele-health. Please contact therapist to determine specific rate.
Payment is due at time of each session. I accept cash, check or credit card. There is a $40 charge for returned check.
EMERGENCIES: In case of emergency, please call Crisis Intervention at 317- 251-7575. If you are experiencing a life- threatening emergency, call 911 or have someone take you to the nearest emergency room for help.
CONFIDENTIALITY: Karen follows all ethical standards prescribed by state and federal law. She is required by practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to you.
Discussions between therapist and client are confidential. To ensure your confidentiality, recording audio or video in your session without the written consent of your therapist is prohibited. No information will be released without the client’s written consent unless mandated by law.
DUTY TO WARN/DUTY TO PROTECT:
When a client discloses intentions or a plan to harm another person, this mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal/health authorities and make reasonable attempts to notify the family of the client.
ABUSE OF CHILDREN AND VULNERABLE ADULTS:
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
Prenatal Exposure to Controlled Substances:
Mental Health professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.
CONSENT TO TREATMENT: By signing this Client Information and Consent Form, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive mental health assessment, treatment and services for me, and I understand that I may stop such treatment or services at any time.