Informed Consent for Counseling

Effective Date: November 1, 2025

 

Counseling is a relationship where we work together to meet your goals. This document explains the process, conditions, and expectations for this work, as well as your rights as a client. Please read this carefully. Signing this document indicates that you have reviewed it, understand it, and agree to its terms.

​

1. About Me and My Approach

 

I am a Licensed Professional Counselor-Supervisor (LPC-S) in Mississippi and licensed as a Mental Health Counselor (LMHC) in Massachusetts.

​

My counseling approach focuses on the present and emphasizes your power to choose how to interpret and respond to your situation. This approach may feel different from other therapy relationships you've had, and though it can lead to positive change, the focus on choice may also be challenging at times.

 

2. Expectations, Risks and Benefits

 

What to Expect

​Therapy involves discussing difficult topics and uncomfortable feelings. I cannot guarantee outcomes, but many clients experience reduced distress, improved relationships, and greater self-awareness over time.

For counseling to be effective, you must be open and honest about your experience in and out of therapy, come to sessions prepared and clear-headed, and be willing to try even when the work is difficult or uncomfortable.

​

Risks, Benefits and Alternatives

Counseling can help reduce distressing feelings, improve relationships, build self-awareness and confidence, find new solutions to problems, and heal past hurts. However, at times, counseling can also cause emotional pain or stress to surface or cause your relationships to change in unexpected ways because of personal changes you’ve made. There are multiple alternatives to counseling, which you can pursue at any point, instead or in addition to therapy. Exercise, meditation and mindfulness practices, self-help and peer-support programs, journaling, and time with animals or in nature are common alternative options. Likewise, medication and other psychiatric interventions may be an option, for some individuals.

​

3. Sessions and Scheduling

​

First Sessions – Assessment and Planning

During the first few sessions (between 1 and 3), I will work to understand your needs, background, experiences, and goals. After this assessment, I will share my initial impressions about what our work might include and how long it might take. At that point, we will develop treatment goals together. You can use this time to assess whether you are comfortable working with me and my approach. If you have concerns, please raise them.

 

Session Scheduling

Sessions typically last 50-60 minutes and are held once per week or once every other week at a time we agree upon, either virtually, or in a location we have chosen together. During particularly stressful times, we may decide to meet more than once per week. If you are late to a scheduled appointment, the session will still end at the scheduled time.

 

Cancellations

Please provide at least 24 hours' notice if you need to cancel or reschedule our session. If you miss a session without canceling (i.e., “no-show”), or cancel with less than 24 hours' notice, I will charge the full session fee, unless circumstances beyond your control prevent your attendance (we will discuss these circumstances together).

 

No-Show Policy

If you fail to attend three (3) scheduled sessions without canceling with 24 hours’ notice, or after you have accumulated 3 no-shows within one calendar year, I will discontinue working with you. Before discontinuing services under this policy, I will try to address attendance or late cancellation issues. If we cannot resolve these barriers and discontinuation becomes necessary, I will offer referrals to other mental health providers.

 

Non-Engagement Policy

If you do not contact me to schedule within 90 days of your last session, I will infer that you to have withdrawn from counseling and terminate our work together. I will make reasonable efforts to contact you before documenting termination, to confirm your intention and to offer referrals to other providers.

 

Privacy During Sessions

No third party will be invited into our sessions without your prior permission. If you wish to invite someone or would like me to invite someone, you should let me know in advance of the session. You should also understand that anything discussed will be known to that person, and I cannot guarantee the privacy of those discussions. Importantly, we may decide to invite your partner to a session, but this would not constitute couples’ therapy, as described below.

 

4. Telehealth Services

​

Technology and Security

If we have elected to meet virtually, we will do so via a secure, encrypted telehealth platform (Zoom Inc.). This platform meets HIPAA security standards, as outlined in the Notice of Privacy Practices. I will maintain records about your therapy services (including diagnosis and clinical treatment progress information) on a secure electronic health record system (Sessions Health), which meets HIPAA security standards. However, no technology is completely risk-free.

 

Your Responsibilities

• Attend sessions only from a private location where others cannot overhear our conversation.

• Use a reliable internet connection and device

• Be physically located in the states where I am licensed while accessing therapy (due to state licensing board regulations). I will not be able to meet with you if you attend from a different state.

 

Technology Failure

If our video connection fails, I will call you. We will attempt to reconnect, or we may complete the session by phone. If technical failure occurs in the first half of the session, we may reschedule. If more than half the session is completed, we may finish by phone or decide to hold only a partial session.

 

Limitations of Virtual Therapy

Telehealth has limitations. I may be less able to help if you become very emotionally distressed or if I cannot clearly see or hear you. Before we begin, I may ask you to identify an emergency contact- someone who could physically assist you during an emergency. If virtual therapy becomes inappropriate for you, I may suggest we pause or meet in person (if possible) or refer you to an in-person therapy provider.

 

5. Contact Between Sessions

​

How to Reach Me

The fastest way to contact me is by email or phone/text. Email and text messages are not secure means of communication, and therefore, involve significant added privacy risks. If you communicate with me using text and/or email, you should not communicate about therapy content.

I will not provide counseling using text messaging or email because there is no evidence that counseling by these methods is effective. If the content of your messages is therapy content, I may suggest meeting for a session or discussing the issue at our next session.

I am not always available and may not respond immediately. When I'm unavailable, you can leave a voicemail, and I will return your call within 24 hours, or on the next weekday (for messages left on a weekend).

 

Emergencies

If you cannot reach me and feel unable to keep yourself safe, or if you're having a mental health crisis:

• Call 988 (Suicide and Crisis Lifeline)

• Go to your nearest hospital Emergency Room

• Call 911

I recommend familiarizing yourself with crisis resources in your state:

• Mississippi: https://www.dmh.ms.gov/help/crisis-services/

• Massachusetts: https://www.mass.gov/info-details/mental-health-crisis-support

If I plan an absence, I will notify you in advance and provide information for a mental health professional covering my practice.

 

Social Media Policy

I do not accept friend requests or follow clients on personal social media. You should not tag me, direct message me about therapy, or comment in ways identifying you as my client. I won't search for or view your social media and won't respond to online reviews or ask you for a review/ testimonial. You are free to tell others you are in therapy, but please consider your own privacy and safety as part of the decision to share.

 

6. Privacy and Confidentiality

 

What Is Confidential

Information you share in counseling is private and confidential. I cannot share it with anyone without your written consent, except under narrow circumstances. Details about all permitted and required disclosures of counseling information are included in the Notice of Privacy Practices.

 

Required Exceptions to Confidentiality

I am required to disclose limited information to specific government agencies or officials, even without your permission, in these situations:

• Imminent danger - You plan to harm yourself or someone else

• Emergency – You are experiencing a medical emergency in session

• Abuse and Neglect - You disclose abuse or neglect of a child, or an elderly or disabled person.

• Lawful order - A court orders me to release information or law requires it

Some of these exceptions are referred to as “Mandatory Reporting Requirements,” or “Duty to Warn / Protect.” These requirements, and the process to fulfill them, vary by state. Should one of these situations arise, assuming it is safe, I will let you know in advance of disclosing any information.

 

Third-Party Payers

If using insurance, your insurer receives diagnosis, treatment plan, and dates of service. If you pay out-of-pocket, information isn't shared without your permission. If you're on someone else's plan, you can request confidential billing.

 

7. Couples or Relationship Counseling (If Applicable)

Specialized expectations and conditions apply to couples’ therapy. Importantly, couples counseling serves the relationship, not either partner’s interests. Both partners jointly “own” the therapy and the record, and my role is to help the relationship itself. As a result, couples therapy is often not covered by third-party payers. In addition, several expectations and rules apply:

• Neither partner can unilaterally release couples’ therapy records.

• Information shared by one partner cannot be kept secret from the other

• Neither partner can continue couples therapy if the other stops

• Individual therapy cannot be provided by the couples’ counselor

• Couples therapy should not be attempted when serious interpersonal violence exists in a relationship

• Virtual couples therapy can be ineffective for high-conflict relationships

 

8. Fees and Payment

 

Session Fees

The full, private-pay fee for each counseling session is $150. You may be charged a reduced amount if we made a reduced fee arrangement.

The agreed-upon session fee, or any co-pay required by your health plan, is due at the time of the session. Fees can be paid by credit card in your client portal account. You are strongly encouraged to set up automatic payments for these fees.

I will not hold another session until you have paid in full for any prior session. If you accrue a balance (from an unpaid session fee or co-pay) and do not pay within 30 days, I may charge a late fee of up to 50% of your balance. After 90 days, I may refer the bill, including any late fees already assessed, to collections.

 

9. Discontinuation of Services

You can end counseling at any time by notifying me that you wish to stop, either in person, by phone, or in writing. If you decide to end counseling, I will offer to help you identify other mental health resources or referrals you need.

 

My Right to Discontinue Services

I may discontinue counseling services if:

• I determine that you are no longer benefiting from our work together

• Continuing counseling would be harmful or detrimental to you

• You engage in threatening or inappropriate behavior toward me or staff

• You do not follow agreed-upon fees and payment terms

• You do not schedule or attend sessions, as described in this agreement

If I discontinue your services for the above reasons, I will provide written notice. I may offer you up to two termination sessions, a referral to another mental health provider, and/or to release your records to another provider of your choice. Any outstanding fees will remain your responsibility.

 

ACKNOWLEDGMENT AND CONSENT

I have read and fully understand this Informed Consent. I have had an opportunity to ask questions and discuss its contents. I voluntarily agree to counseling services under the terms and conditions described above.
I know I can withdraw this consent at any time by notifying my therapist.