CLIENT CONSENT FORM

Counseling is a helping process where professionals in the field work with clients in order for
clients to better process and understand random life situations and issues the latter may
encounter.

Bonded by oath and professional ethics, the principle of confidentiality is greatly practiced.
Discussions will remain within the corners of the clinic and no disclosure will be given
without client’s consent. Copy of report

Terms of Service:

 Early arrival prior to session is advised. Notify the therapist for late notice or for cancellation at
least 2 hours before the session. Contact information is printed below. Follow the agreed schedule
for better services. The therapist have the right to cancel or terminate session to clients who have
repeated absences or late. This is to show consideration as well to others who faithfully attend
their assigned schedules. On the other hand, the therapist has the right to cancel sessions in case
of personal emergencies and if upon assessment client is medically ill.
 The total number of sessions will be informed as soon after intake interview and will be discussed
further. However, meetings will be for one hour per client. There may be events that the number of
meetings may be increased or decreased depending on the assessed needs.
 The relationship between the therapist and client is purely professional. Anything that goes
beyond the said relationship can destabilize the effectiveness of the therapy. The therapist swore
to take of every client but is not in the position of being a friend or equivalent to that.
 Client may request for copy of report at the end of the session but please be considerate that it
would take a month for the report to be fully furnished.
 After hour emergencies are considered especially for life and death matters.
 Administration of further tests may at times be given and these will comprise additional payments.
Keep in mind that such process is given to provide greater assessment and understanding of
client’s needs.
 Payments will be discussed in face-to-face manner with the therapist.

Grounds for the Execution of Confidentiality

 Threat of harm to others or to self which may be grounds for termination of treatment
 A court order
 Referral or consultation with other helping professionals

I have read and discussed the above information with my therapist. I understand the risks
and benefits of counseling, the nature and limits of confidentiality, and what is expected of
me as a client.

ALLEN KEVIN C. ALIÑO

SIGNATURE OVER PRINTED NAME DATE

MARIANNE A. DOMINGO-0998-XXX-XXXX