Informed Consent Form

Therapist’s Name
Address
Office Phone / Office Email
Office Hours

INTRODUCTION

Good day! Welcome to my practice. Therapy is a process that varies depending on the
personalities and the problems the patient hope to address. As a counselor, I am here to help you
overcome these concerns with strategies and approach that I believe will benefit you. Therapy
may have its advantages and risks that’s why it is important that you choose the counselor that
you are comfortable speaking to, and a treatment plan that you agree with.

Please read this form carefully for you to be fully aware of your rights and our
responsibilities in this relationship. Please approach me with any questions that you might have
so I can explain them to you. This document will serve as our agreement, when you sign below.

WHO AM I? HOW DOES THE THERAPY WORK?

I am a registered psychotherapist in the country. My area of expertise is women’s issues. I

am specifically working with survivors of rape, domestic physical violence and psychological
abuse. The first few meetings are usually spent to evaluate whether I am the best person to help
you with your recovery. If one of us believes otherwise, I will help you set up a meeting to other
professionals that might be better suited for you.

If we come to an agreement, I will schedule (1-hour) sessions to be conducted per week, at a

time we decide on. Some sessions may be longer and more frequent, if needed. These sessions
intend to identify and acknowledge your mental health condition, and I, as your therapist, will
guide you in your healing journey.

If you are unable to attend due to unforeseen circumstances, please provide an advance
notice so we may reschedule the appointment at a date convenient for us both.

Insert BENEFITS AND RISKS OF [THERAPY METHOD APPROACH 1]

Insert BENEFITS AND RISKS OF [THERAPY METHOD APPROACH 2]
Insert BENEFITS AND RISKS OF [THERAPY METHOD APPROACH 3]
WHAT IS MY RESPONSIBILITY TO YOU AS YOUR THERAPIST?

The counseling sessions involve discussing private and sensitive information. The crucial
part of an effective therapy is the privacy of the patients. Although I am responsible to keep brief
records of what we have talked about, (these meetings may include audio/video recording and
note taking) I am legally prohibited to speak of these materials and our conversations to others
unless under the following circumstances:

1. If a child may cause serious harm to themselves or may be at risk of abuse from others and,
if I believe that someone may have the ability to do these threats, I must inform a guardian
or security officer of the information that I have to prevent this from happening.

2. If I believe that you, my patient, is at risk of imminent danger, I am required to report to a

guardian and/or police of the information that I have to protect them.

3. If a legal order is delivered by the court or a client case is involved in a criminal

proceeding, I am required to disclose information needed by the authorities.

4. You may also allow me to share information to another person, provided with a written
consent.

5. I may also obtain a written waiver to be able to use these materials in my writings, research
and publications with the considerations of protecting the identity of the patient/client
involved.

6. If you decide to have a couples’ therapy with your partner, refrain from sharing
information that you do not want your partner to know about. For the efficiency of the
therapy, I cannot maintain confidentiality. I will use and discuss these to you and your
partner.

CONTACT INFORMATION
You may contact me through the number provided in this document if:
1. If you need to notify me of your absence for the next week’s session.
2. If you have any questions or concerns regarding the services that I render. If I am on
vacation, I will provide a contact information of a person you may contact.

Please be reminded that non-emergency matters shall be discussed in our sessions. However,
if you have any complaints with my services which you choose not to discuss with me, you may
contact the Review Board at xxxx-xxxx (ext xxx).
 In the case of life-threatening emergencies, please direct to the authorities or to the nearest
emergency room.
OTHER RIGHTS

It is important for you to know that you have the right to ask questions throughout the
therapy about the approach we are doing in the sessions. You may request of a copy of the
records I kept for your reference.
As part of your healing, you may also suggest to try something that you believe will be
helpful for you. And also, if in the process of our therapy, you feel like I am not the right
therapist for you, you may leave any time. You may request for referral of another professional
that I recommend for you to see.

CONSENT

I have read and discussed the information in this form, and had the answers to the questions I
raised.
I understand that by signing below I fully understand and agree to the following:
❑ The qualification, limits and therapeutic approach of the counselor
❑ Risks and benefits of the therapy method approach we may use
❑ The nature and exceptions of confidentiality
❑ My responsibilities as a client of the Counseling Services.
I am fully aware that I can continue or end the therapy at any time I desire and that I can refuse
any requests or suggestions made by the therapist.

_________________________________ ______________________________

Name of Client Name of Therapist

_________________________________ ______________________________

Signature of Client Signature of Therapist

_________________________________ ______________________________

Date signed Signature of Witness (if any)