This document sets forth a standard disclosure statement for use by a professional
counselor. The counselors provide this disclosure statement to their clients to limit their
potential liability and to set forth the rights and obligations of both parties during the
relationship. In addition, this form sets out fees, insurance, confidentiality, and risks.
This document should be used by counselors that want to formalize an agreement with
Professional Counseling Disclosure
[Pick the date]
Professional Counseling Disclosure Statement
Therapy such as counseling can be a long commitment of time, and money,
therefore a counselor should be carefully chosen. You should be at ease, and
confident with the counselor you choose. This Disclosure Statement is
designed to help you make your decision in choosing us as your therapists
in an informed consensual manner.
Counseling requires your very active involvement and offering your views
and responses when they are important to you. This affords the counselor’s
efforts to give input, and feedback in order to help you see that you and you
alone can change your thoughts, actions and feelings. I will expect you to be
open about what you are thinking. No help can be gained without dialog.
My jobs are to guide, calm, and encourage you. In our counseling, you may
have record-keeping, reading assignments, calisthenics, and practice tests.
You most certainly will have to make long term efforts in relationships in
order to have a positive outcome from your counseling sessions. Your life
outcome will in fact depend upon you, and your willingness to change.
I will ask for regular reviews of our progress and if treatment is not
progressing, I may refer you to another professional. I will fully discuss this
ahead of time so that we can come to an agreement.
I see therapy as collaboration between counselor and counselee, and by the
second session I will be able to offer you my initial response, and tell you
what I think, and feel about your situation, and recommend a treatment
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The treatment plan will approximate the costs, and time commitment
involved, along with other aspects of your situation in a meticulous detailed
manner. I expect us to agree upon the treatment plan, and your
commitment to strive to adhere to its progress goals, and methods.
Risks of isolation, rage, dissatisfaction, guilt, anxiety and sadness may
occur. You may recall distasteful aspects of your times past; and difficulty
with people important to you may occur; notwithstanding your and my
greatest efforts, counseling may not work out well for your individual
situation. Some changes you may make could lead to a deterioration of your
Notwithstanding, therapy has been scientifically demonstrated to be of
benefit. You will have the occasion to "talk things out" utterly, which might
bring with it the lifting of depression, fear, anxiety, or anger. You may be
better equipped to cope with social and family relationships; your people
skills may improve dramatically even leading to job promotion.
The first introduction and information gathering session will take one and
one half hours, but future sessions are at one hour intervals. Typically we
will book and schedule sessions more often over the first three months and
then monthly for several months. An appointment is a contract between
us. We agree to be here and on time, if you are late we will probably be
unable to meet for the full session as it is likely that another appointment is
scheduled after yours.
Your session time is reserved for you. Please make this your first priority we
may in the future bill for missed scheduled sessions.