Informed Consent
LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal
information and written records about a client cannot be shared with another party
without the written consent of the client or the client’s legal guardian. Noted exceptions
are as follows:
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health
professional is required to warn the intended victim and report this information to legal
authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to
notify the family of the client.
Abuse/Neglect of Children and Vulnerable Adults
If the counselor becomes aware during the course of treatment of any abuse/neglect or danger of abuse/neglect to a child (or vulnerable adult), then the counselor is required to report this information to the appropriate social service and/or legal authorities.
Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the
clients’ records.
I agree to the above limits of confidentiality and understand their meanings and
ramifications.
__________________________________________________________________________
Client Signature (Client’s Parent/Guardian if under 18)
________________________________
Today’s Date
CANCELLATION POLICY
If you need to cancel an appointment, you must give 24 hours notice. A full fee for the session is charged for missed appointments or no-show cancellations with less than a 24 hour notice unless due to illness or an emergency. Thank you for your consideration regarding this important matter.
COUNSELING SESSIONS AND FEES
Counseling sessions last 50-60 minutes. If you are late, your session will end at the time it was originally scheduled to end. This is done so that your counselor can be prompt with
appointments that follow yours.
CONSENT TO TREAT
Please sign below to indicate that you have read ALL the above policies and that you
understand and agree to comply with them. Your signature indicates that you have had a
chance to ask your counselor any questions you might have about these policies and that your questions have been satisfactorily answered. You agree that you are personally responsible for all financial obligations incurred. Finally, you consent to receive treatment by Francesca LoMonaco, LCSW.
Print name:___________________________________________________________________
__________________________________________________________________________
Client Signature (Client’s Parent/Guardian if under 18)
________________________________
Today’s Date
____________________________________________________________________________
(Counselor signature)
LIMITS OF CONFIDENTIALITY
Contents of all therapy sessions are considered to be confidential. Both verbal
information and written records about a client cannot be shared with another party
without the written consent of the client or the client’s legal guardian. Noted exceptions
are as follows:
Duty to Warn and Protect
When a client discloses intentions or a plan to harm another person, the mental health
professional is required to warn the intended victim and report this information to legal
authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to
notify the family of the client.
Abuse/Neglect of Children and Vulnerable Adults
If the counselor becomes aware during the course of treatment of any abuse/neglect or danger of abuse/neglect to a child (or vulnerable adult), then the counselor is required to report this information to the appropriate social service and/or legal authorities.
Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the
clients’ records.
I agree to the above limits of confidentiality and understand their meanings and
ramifications.
__________________________________________________________________________
Client Signature (Client’s Parent/Guardian if under 18)
________________________________
Today’s Date
CANCELLATION POLICY
If you need to cancel an appointment, you must give 24 hours notice. A full fee for the session is charged for missed appointments or no-show cancellations with less than a 24 hour notice unless due to illness or an emergency. Thank you for your consideration regarding this important matter.
COUNSELING SESSIONS AND FEES
Counseling sessions last 50-60 minutes. If you are late, your session will end at the time it was originally scheduled to end. This is done so that your counselor can be prompt with
appointments that follow yours.
CONSENT TO TREAT
Please sign below to indicate that you have read ALL the above policies and that you
understand and agree to comply with them. Your signature indicates that you have had a
chance to ask your counselor any questions you might have about these policies and that your questions have been satisfactorily answered. You agree that you are personally responsible for all financial obligations incurred. Finally, you consent to receive treatment by Francesca LoMonaco, LCSW.
Print name:___________________________________________________________________
__________________________________________________________________________
Client Signature (Client’s Parent/Guardian if under 18)
________________________________
Today’s Date
____________________________________________________________________________
(Counselor signature)
