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.
You are responsible for assuring that services are paid for; this makes it
more likely that the counseling sessions will work. The current regular fee
for therapy is $<___> per hour. In financial hardship we may, before the
end of our first meeting, negotiate a sliding scale fee.
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You must pay for each session at the end of the session. If you have health
insurance which may pay a portion of the costs for your therapy, I will
provide you with insurance claim forms. However, please bear in mind that
you are responsible and not your insurance company, for paying the fees.
As a Licensed <___________>, my services for evaluation and
psychotherapy are reimbursable to you fully or partly under many health
insurance plans. For some plans you may need to get a physician's referral
for psychotherapy, so search your plan carefully.
You can apply for reimbursement by simply mailing a completed copy of
your companies Claim Form which you can get from your employer's
Benefits Office or by calling the insurance company.
Insurance Claim Forms are now guided by HIPAA regulations and as such
they become part of your permanent medical record, its possible influence
on your future should be discussed with your attorney.
The confidentiality of our conversations, including your records, is legally
protected by federal and state law, including HIPAA, and by my
profession's ethical principles. These are outlined in my handout on
Confidentiality and Psychotherapy, which is also being provided to you. I
make every effort to preserve the confidentiality and anonymity of all my
clients. Other people do not see my clinical records. I ask each client to
preclude disclosing the distinctiveness, or names of any other clients being
seen at this office.
VII. General Information
Each counselor has developed rules or methods which have worked well
doing therapy. I often take notes and also ask my clients to take notes, both
during the session and at home. This is a vital factor in personal change and
I expect my clients to take notes in order to maximize your therapy dollars.
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You have the right to review your medical record within HIPAA limitations
at any time, and to obtain copies for other professionals to use. I will keep
your case records in a secure place for at least 12 years, after our last
IX Contact Person
If, there is an emergency or I become concerned about your personal safety
or the possibility of your injuring someone else, I am morally and legally
obliged to contact the appropriate officials, or the person listed as a contact
on your intake forms.
X My background
PROFESSIONAL ORIENTATION AND TRAINING:
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XI Code of Ethics:
I am a licensed <__________>, which means that I abide by the ethical
and legal responsibilities outlined for Mental Health practitioners. Like any
other health care professional I have an ethical responsibility. I fully abide
by the Ethical Principles of the <___________> Association and the
<_____> Board of Examiners for Licensed <____________>.
I am not licensed to practice law, medicine, or another profession and am
neither willing nor capable of giving you trustworthy advice from other
professional points of view.
In my professional practice, as Licensed <_____>, I nor my practice
discriminate in accepting and treating patients, clients, students or others
on the basis of: age, gender, marital status, race, color, religion, ancestry,
national ethnicity, location of residence, physical or mental disability,
veteran status, or in violation of any federal, state or local law. This
statement is made in accordance with federal, state and local regulations.
I, the counselor, find no reason to believe that this client is not fully
competent and of competent mind to give full consent to treatment.
I have read (or had read to me) the contact above, discussed it, and where I
was not clear about any point, had my questions fully answered, and I agree
to comply with this contract, I hereby agree to enter into psychotherapy
with this counselor as indicated by my signature below.
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