GREENLEAF COUNSELING SERVICES
INFORMED CONSENT FORM
Welcome to Greenleaf Counseling Services. I appreciate the opportunity to be of help to you. The following
information answers some questions clients often ask about any therapy practice. It is important to me that
you know how we will work together. I believe our work will be most helpful to you when you have a clear
idea of what we are trying to do.
PLEASE TAKE THE TIME TO READ THE FOLLOWING DOCUMENT THOROUGHLY!
This information document talks about the following in a general way:
• What the risks and benefits of therapy are.
• What the goals of therapy are and what my methods of treatment are like.
• How long therapy might take.
• How much my services cost and how I handle money matters.
• Other important areas of our relationship.
After you read this information we can discuss, in person, how these issues apply to your own situation.
Please read all of it and mark any parts that are not clear to you. Write down any questions you think of,
and we will discuss them at our next meeting. When you have read and fully understood this information, I
ask you to sign it at the end.
Collaboration.
Because you will be putting a good deal of time, money, and energy into therapy, you should choose a
therapist carefully. I strongly believe you should feel comfortable with the therapist you choose, and hopeful
about the therapy. Choose a therapist that you connect with not one based solely on fee cost, convenient
location, degree, etc. When you feel this way, therapy is more likely to be very helpful to you. Let me
describe how I see therapy.
My general theoretical belief is based on a psychodynamic and systems approach. The most central ideas
in my work are that present unhealthy patterns of relating or coping are developed in relationships; these
may be in early formative relationships as well as current marital or familial relationships. Most of our
struggles or pain comes from relationships and how we view ourselves and our world. Therefore healing in
our life comes when we learn the basis of our identity, learn how to effectively give and receive in our
relationships, and in therapy itself experience respect, trust, and authentic relating. The general goals of my
treatment are to help you resolve current distressing events in your life and help you grow as a person.
Course of Treatment.
Our first session generally includes a summary from you (and your spouse or family if it is marriage or
family therapy) about what brings you to therapy; that is we will discuss the general issues that bring you to
therapy at this time. I will also discuss the informed consent information in this document and any other
questions about therapy you may have. By the end of our first session we will decide together which
direction to proceed in - whether to continue therapy, seek a referral, etc. If we decide to continue therapy, I
will need to spend approximately 2-5 sessions getting to know more about you (as an
individual/couple/family). I will want to get a condensed “running” history of your life accompanied by
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detailed information about your family of origin. You may be asked to do a genogram and structural map
which outlines your family of origin as a homework assignment. Couples will also be asked to complete
several forms to assist in the assessment process. I will give you the information you need to properly do all
this. There will most likely be additional costs for the professional assessments.
After completing the history taking we will talk about the goals of therapy. I will ask you to specify what it is
that you want to accomplish in therapy and I will also give you my feedback on the issues I am hearing. We
will collaborate in finalizing your therapy goals. I expect us to agree on a plan that we will require hard work
for both of us. From time to time, we will look together at progress and goals. If we think we need to, we
can then adjust our therapy plan.
Psychotherapy requires your initiative and very active involvement. It requires your best efforts to change
thoughts, feelings, and behaviors. I want you to tell me about important experiences, what they mean to
you, and what strong feelings are involved. I will also expect you to take the initiative to begin each session
and to take the initiative in raising your concerns in session. For example, over 50% of adults have sex
problems, sexual dysfunction, or sexual dissatisfaction. If this is an area of your life where there are
struggles then raise this issue in session and in that way you gain some sense of control over your
process/progress. This is one of the ways you are an active partner in therapy.
An important part of your therapy will be practicing new ideas and skills that you will learn in our sessions. I
will ask you to reflect and practice outside our meetings, and we will work together to set up some
homework assignments for you. I might ask you to do exercises, to keep records or a journal, and perhaps
to do other tasks to deepen your learning. You will probably have to work on relationships in your life and
make long-term efforts to get the best results. These are important parts of personal change. Change will
sometimes be easy and quick, but may just as often be slow and frustrating, and you will need to keep
trying. There are no instant, painless cures and no “magic pills.” However, we will work hard to learn new
ways of looking at your problems that will be very helpful for changing your feelings and reactions.
If we are doing couples/marriage therapy, I like to do our sessions with everyone present. I may ask to do a
session with each of you individually or you may ask for an individual session but if I offer one partner an
individual session I will also offer the other partner the same. You have hired me as a professional to help
you fight for your relationship or marriage. If at any time in our therapy I learn something your spouse is not
aware of - be it a secret or just something you haven't shared with them yet - you agree to allow me to use
my professional judgment in determining how to handle that information toward our shared goal of growth
and relational maturity. That means if you share a secret with me, you are trusting my professional
judgment in whether I share that with your spouse or not. If I choose to share the information with your
spouse in a session, you know that I believe it is the best option in fighting for your marriage. You also
allow me to NOT share information with you I have learned from your spouse. If I keep a secret from you,
you know I am doing so from my professional judgment.
Please know that my general practice is to not share secrets but help you to share them. If you are keeping
a secret, it would be valuable for me to know this information so I can grow your marriage up to the point
that you can share this information with your spouse. If a secret puts me in the middle of your marriage in
an unhealthy way, I may chose to share the information so I can help your marriage continue to grow.
Whatever my decision, I need you to understand that I am acting in what I think is the best interest of your
relationship. Also, if your relationship with your partner is in trouble and he/she does not want to work on
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the relationship in therapy, much good can still occur even when one person in the relationship is working
and growing.
Another benefit in therapy can be the viewing of yourself by audio or videotape. In doing couples therapy I
will want to tape our sessions for the purpose of allowing you to see or hear yourself and your style of
effective or ineffective communicating with your partner. Any recording will only be used in our therapy
session(s) and will not be viewed by any other person without your express written consent.
Because of the nature of psychotherapy I cannot guarantee exactly how long therapy will take. We will
evaluate progress intermittently to gauge the direction and progress of therapy. Most of my clients see me
at least once a week, sometimes more frequently initially, until we are coming to the end of therapy and will
meet less often for a few more weeks or months. Therapy then usually comes to an end. The process of
ending therapy, called “termination,” can be a very valuable part of our work. Stopping therapy should not
be done casually, although either of us may decide to end it if we believe it is in your best interest. If you
wish to stop therapy at any time, I ask that you agree now to meet then for at least one session to review
our work together. We will review our goals, the work we have done, any future work that needs to be done,
and our choices. If you would like to take a “time out” from therapy to try it on your own, we should discuss
this before making a decision.
Once you terminate therapy, the opportunity to return to therapy at another time remains open. Many
clients will return at a later time to deal with a particular concern or for an emotional or mental health “check
up.”
I will send you a brief set of questions about 6 months after our last session. These questions will ask you
to look back at our work together, and sending them to you is part of my duty as a therapist. I ask that you
agree, as part of entering therapy with me, to return this follow-up form and to be very honest about what
you then tell me.
The Benefits and Risks of Therapy
As with any powerful treatment, there are some risks as well as many benefits with therapy. You should
think about both the benefits and risks when making any treatment decisions. For example, in therapy,
there is a risk that you will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger,
frustration, loneliness, helplessness, or other negative feelings. You may recall unpleasant memories.
These feelings or memories may bother you at work or in school.
In addition, if someone knows that you come for therapy some people mistakenly view anyone in therapy
as weak or perhaps as “having problems.” Also, a client in therapy may have problems with people
important to them. Family secrets may be told. Therapy may disrupt a marital relationship and sometimes
may make things more difficult for awhile as old patterns are changed. Most of these risks are to be
expected when people are making important changes in their lives. Finally, even with our best efforts, there
is a risk that therapy may not work out well for you.
While you consider these risks, you should know also that the benefits of therapy have been shown by
scientists in hundreds of well-designed research studies. People who are depressed may find their mood
lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things
out fully until their feelings are relieved and/or the problems are solved. Relationships and coping skills may
improve greatly. You may get more satisfaction out of social and family relationships. You may find your
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relationship with God to be clearer and more fulfilling. You may improve your ability to realize life goals.
You may grow in many directions—as a person, in close relationships, in work or schooling, and in the
ability to enjoy life.
I do not take on clients I am unsure that I can help. Therefore, I will enter our relationship with optimism
about our progress.
Consultations
If you could benefit from a treatment I cannot provide, I will help you to get it. You have a right to ask me
about other treatments, their risks, and their benefits; I will explain to you what I know. Based on what I
learn about your problems, I may recommend a medical exam, a visit to a psychiatrist for medication, or
psychological testing. If I do this, I will fully discuss my reasons with you, so that you can receive the best
treatment. If you are treated by another professional, I will coordinate my services with them and with your
own medical doctor.
If for some reason treatment is not going well, I might suggest you see another therapist, or another
professional in addition to me. As a responsible person and ethical therapist, I will not continue to treat you
if I feel my treatment is not working for you. If you wish for another professional’s opinion at any time, or
wish to talk with another therapist, I will help you find a qualified person and will provide him or her with the
information needed per your release.
What to Expect from Our Relationship
As a professional, I will use my best knowledge and skills to help you. This includes following the standards
of the American Association of Marriage and Family Therapists (AAMFT) and the Licensed Professional
Counselors Association of Georgia (LPCGA) of which I am a member. In your best interests, the AAMFT
and LPCGA puts limits on the relationship between a therapist and a client, and I will abide by these. Let
me explain these limits, so you will not think they are personal responses to you.
First, I am licensed and trained to practice psychotherapy—not law or medicine or any other profession. I
am not able to give you expert advice from these other professional viewpoints.
Second, state laws and the rules of AAMFT and LPCGA require me to keep what you tell me confidential
(that is, private). You can trust me not to tell anyone else what you tell me, except in certain limited
situations. I explain what those are in the “About Confidentiality” section of this information. Here I want to
explain that I try not to reveal who my clients are. This is part of my effort to maintain your privacy. If we
meet on the street or socially, I may not say hello or talk to you very much. My behavior will not be a
personal reaction to you, but a way to maintain the confidentiality of our relationship.
Third, in your best interest, and following the AAMFT and LPCGA’s standards, I can only be your therapist.
I cannot have any other role in your life. I will not, now or ever, be a close friend with any of my clients. I
cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic
relationship with any client during, or after, the course of therapy. Even though you might invite me, I will
not attend your family gatherings, such as parties or weddings.
As your therapist, I will not give you gifts; I may not recall your birthday; and while gifts you give me are
appreciated, I will be careful in accepting any gifts from clients if I feel they might change our professional
relationship.
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About Confidentiality
I will treat with great care all the information you share with me. It is your legal right that our sessions and
my records about you are kept private. That is why I ask you to sign a “release-of-information” form before I
can talk about you or send my records about you to anyone else. In general, I will tell no one what you tell
me. I make every effort to not even reveal that you are receiving treatment from me.
In all but a few rare situations, your confidentiality is protected by state law and by the rules of my
profession. Here are the most common cases in which confidentiality is not protected:
1. If you were sent to me by a court or an employer for treatment or some type of evaluation, the court
or employer may expect a report from me. If this is your situation, please talk with me before you
tell me anything you do not want the court or your employer to know. You have a right to tell me
only what you are comfortable with telling.
2. Are you suing someone or being sued? Are you going through a divorce? Are you being charged
with a crime? If so, and you tell the court that you are seeing me, I may then be ordered to show
the court my records. I will do all I can to prevent that from happening since such disclosure can
negatively affect our relationship. Please consult your lawyer about these issues.
3. If you make a serious threat to harm yourself or another person, the law requires me to try to
protect you and/or that other person. This usually means telling others about the threat. I will not
promise to not tell others about threats you make.
4. If I believe a child has been or will be abused or neglected, I am legally required to report this to the
authorities. If an elderly person is being abused in any way or taken advantage of financially, I am
legally required to report this.
5. If we are doing couples or family therapy I cannot guarantee that information you disclose will be
kept confidential by other members in therapy. The same is true if we are doing group therapy.
There are two situations in which I might talk about part of your case with another therapist. I ask now for
your understanding and agreement to let me do so in these situations:
1. When I am away from the office for a few days, I have trusted fellow therapists who may “cover” for
me. This therapist(s) will be available to you in emergencies. Therefore, he or she needs to know
about you. Of course, this therapist is bound by the same laws and rules as I am to protect your
confidentiality.
2. I sometimes consult other therapists or other professionals about my clients. This helps me in
giving high-quality treatment. These persons are also required to keep your information private.
Your name will never be given to them, and they will be told only as much as they need to know to
understand your situation.
For the purpose of these consultations, I may want to make audio or video recordings of our sessions. I will
review the recordings with my consultant to assist with your treatment. I will not make any recording without
first asking your permission. I promise to destroy each recording as soon as I no longer need it, or, at the
latest, when I destroy your case records.
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Except for the situations I have described above I will always maintain your privacy. I also ask you not to
disclose the name or identity of any other client being seen in this office.
If your records need to be seen by another professional, or anyone else, I will discuss it with you. If you
agree to share these records, you will need to sign a release form. This form states exactly what
information is to be shared, with whom, and why, and it also sets time limits. You may read this form at any
time. If you have questions, please ask me.
It is my office policy to destroy clients’ records 7 years after the end of our therapy. Until then, I will keep
your case records in a safe place.
If I must discontinue our relationship because of illness, disability, or other presently unforeseen
circumstances, I ask you to agree to my transferring your records to another therapist who will assure their
confidentiality, preservation, and appropriate access.
If we do family or couple therapy (where there is more than one client), and someone wants to have my
records of this therapy sent to anyone, all of the adults present will have to sign a release.
As part of cost control efforts, an insurance company will sometimes ask for more information on
symptoms, diagnoses, and my treatment methods. It will become part of your permanent medical record. I
will let you know if this should occur and what the company has asked for. Please understand that I have
no control over how these records are handled at the insurance company. My policy is to provide only as
much information as the insurance company will need to pay your benefits.
For the benefit of our therapeutic relationship I will not allow you to review your records in my files. I take
notes that will benefit me but your viewing of them may not be in the context in which they were written and
therefore may be misunderstood. I also ask you to understand and agree that you may not examine
records created by anyone else and sent to me.
My Background
I am a therapist with over 20 years of counseling experience. For the past 6+ years, I have had my own
office for the general practice of counseling. I am trained and experienced in doing one-on-one and couples
therapy. I am also trained and experienced in doing family therapy where the children are developed
enough to talk about how they think and feel. Earlier in my career, I worked in psychiatric hospitals and in a
private practice setting. I hold these qualifications:
• I have a doctoral degree in counseling from Columbia Theological Seminary, whose program is
approved by the Southern Association of Colleges and Schools (SACS) and the Association of
Theological Schools (ATS).
• I have done post-doctoral work in the area of Marriage and Family Therapy at the University of Georgia
(Athens, Ga.) and at Psychological Studies Institute (Atlanta, Ga.).
• I have experience working in psychiatric settings as a chaplain and substance abuse counselor and
presently as a private practice therapist.
• I completed a 3 year internship in counseling as part of my doctoral work.
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• I have completed the requirements for licensure as a Professional Counselor and Marriage and Family
Therapist in Georgia. I am a clinical member of the American Association of Marriage and Family
Therapists (AAMFT) and professional member of the Licensed Professional Counselors Association of
Georgia (LPCAGA). I am also certified by the National Board of Certified Counselors (NBCC) as a
nationally certified counselor (NCC).
About Our Appointments
The very first time I meet with you, we will need to give each other much basic information. For this reason,
I usually schedule 1 or 2 50-minute sessions for this first meeting. Following this, we will usually meet for a
50-minute session once or twice a week. We can schedule meetings for both your and my convenience. I
will attempt to tell you at least a week in advance of my vacations or any other times we cannot meet.
Please ask about my schedule in making your own plans.
An appointment is a commitment to our work. We agree to meet at my office and to be on time. If I am ever
unable to start on time, I ask your understanding since occasional emergencies arise with other clients in
the course of a day. I also assure you that you will receive the full time agreed to. If you are late, we will
most likely be unable to meet for the full time, because it is likely that I will have another appointment after
yours.
A cancelled appointment delays our work. I will consider our meetings very important and ask you to do the
same. Please try not to miss sessions if you can possibly help it. When you must cancel, you must give me
a minimum of 24 hours notice. Your session time is reserved for you. I am rarely able to fill a cancelled
session unless I know 24 hours in advance. If you miss a session without the 24 hours advance notice,
I will charge you for the lost time. Your insurance will not cover this charge.
I will reserve a regular appointment time for you as soon as possible. I also do this for my other clients.
Therefore, I am rarely able to fill a cancelled session unless I have adequate notice. You will be charged
the full fee for sessions cancelled with less than 24 hours’ notice. Please initial here to indicate that
you understand this policy. _____________
I request that you do not bring children with you if they are young and need babysitting or supervision,
which I cannot provide. I do not have toys, but I can provide reading materials suitable for older children but
they will need to stay in another room during our meeting. However, it is best if you do not bring your
children unless you are certain they can be in a separate room and remain quiet.
Fees, Payments, and Billing
Payment for services is an important part of any professional relationship. This is even more true in
therapy; one treatment goal is to make relationships and the duties and obligations they involve clear. You
are responsible for seeing that my services are paid for. Meeting this responsibility shows your commitment
and maturity. GCS is dedicated to providing the highest quality service at a reasonable price. Fee policies
of GCS arise out of a professional identity, and combine spiritual, ethical, psychological, and financial
considerations. This means that the fees are competitive with similar psychotherapy services in the
community, and that within the dictates of sound fiscal policy, clients will not be turned away for financial
reasons.
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Assessments: For some individuals and for most couples I ask that several different assessments be
completed before our first or second meeting. Together these assessments may take a little time but will
assist the initial process. There is an additional cost for each of the assessments beyond the cost of the
session time and that cost is approximately $60 for the marital adjustment test, multi-axial test, and sexual
history assessment.
My current regular fees are as follows. You will be given advance notice if my fees should change.
Regular therapy services: For a session of 50 minutes, the fee ranges from $100 to $130. Please pay for
each session at the beginning. I have found that this arrangement helps us stay focused on our goals,
and so it works best. It also allows me to keep my fees as low as possible, because it cuts down on my
bookkeeping costs. I suggest you make out your check before each session begins, so that our time will be
used best. Other payment or fee arrangements must be worked out before the end of our first meeting.
Telephone consultations: I believe that telephone consultations may be suitable or even needed at times in
our therapy. If so, I will charge you our regular fee, prorated over the time needed. If I need to have long
telephone conferences with other professionals as part of your treatment, you will be billed for these at the
same rate as for regular therapy services. If you are concerned about all this, please be sure to discuss it
with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge
for calls about appointments or similar business.
Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone
work on a particular issue. When this extension is more than 10 minutes, I will tell you, because sessions
that are extended beyond 10 minutes will be charged on a prorated basis.
Reports: I will not charge you for my time spent making routine reports to your insurance company.
However, I will have to bill you for any extra-long or complex reports the company might require. The
company will not cover this fee.
Other services: Charges for other services, such as hospital visits, consultations with other therapists,
home visits, or any court-related services (such as consultations with lawyers, depositions, or attendance at
courtroom proceedings) will be based on the time involved in providing the service at my regular fee
schedule. Some services may require payment in advance.
I realize that my fees involve a significant amount of money, although they are well in line with similar
professionals’ charges. For you to get the best value for your money, we must work hard and well.
I will assume that our agreed-upon fee-paying relationship will continue as long as I provide services to
you. I will assume this until you tell me in person or by certified mail that you wish to end it. You have a
responsibility to pay for any services you receive before you end the relationship.
I will not send you a statement unless you ask for it. The statement can be used for health insurance
claims, as described in the next section. It will show all of our meetings, the charges for each, how much
has been paid, and how much (if any) is still owed.
If you think you may have trouble paying your bills on time, please discuss this with me. I will also raise the
matter with you so we can arrive at a solution. If your unpaid balance is over $200, I will notify you by mail.
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If it then remains unpaid for over 7 days, I must stop therapy with you. Fees that continue unpaid after this
will be turned over to small-claims court or a collection service.
If there is any problem with my charges, my billing, your insurance, or any other money-related point,
please bring it to my attention. I will do the same with you. Such problems can interfere greatly with our
work. They must be worked out openly and quickly.
If You Have Traditional (or “Indemnity”) Health Insurance Coverage
Because I am a licensed therapist, many health insurance plans will help you pay for therapy and other
services I offer. For some insurance companies I am an “out-of-network” provider and for others I am an
“in-network” provider and insurance companies pay certain amounts or percentages accordingly. You will
need to check with your insurance provider to determine whether I am in-network or out-of-network.
Because health insurance is written by many different companies, I cannot tell you what your plan covers.
Please read your plan’s booklet under coverage for “Outpatient Psychotherapy” or under “Treatment of
Mental and Nervous Conditions” or call your employer’s benefits office to find out what you need to know.
Before we meet you should also know if your coverage provides for counseling by an LMFT (Licensed
Marriage and Family Therapist) or an LPC (Licensed Professional Counselor) and you will need to find out
(if we are doing couples/marriage therapy) if marriage therapy is covered. Unfortunately, most insurance
companies do not cover marital therapy so if we are conducting marital or couples therapy you will most
likely have to pay out-of-pocket for this type of therapy.
If your health insurance will pay part of my fee, I will help you with your insurance claim forms. However,
please keep two things in mind:
1. I had no role in deciding what your insurance covers. Your employer decided which, if any,
services will be covered and how much you (and I) will be paid. You are responsible for checking
your insurance coverage, deductibles, payment rates, co-payments, and so forth. Your insurance
contract is between you and your company; it is not between me and the insurance company. Most
insurance companies do not cover marriage or couples therapy.
2. You—not your insurance company or any other person or company—are ultimately responsible for
paying the fees we agree upon. If you ask me to bill a separated spouse, a relative, or an
insurance company, and I do not receive payment on time, I will then expect this payment from
you.
MAKE SURE YOU CLEARLY UNDERSTAND THE FOLLOWING!
To seek payment from your insurance company, you must first obtain a claim form from your employer’s
benefits office or call your insurance company. Complete the claim form. Then attach my statement to the
claim form and mail it to your insurance company. My statement already provides the information asked for
on the claim form. In other words, paying for therapy works in this manner:
1. You will pay me my fee each week (or as agreed upon) for psychotherapy services that are
provided.
2. I will give you a receipt showing your payment to me.
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3. You will attach the receipts to your insurance company’s form for reimbursement or submit them
electronically.
4. I do not file the claims for you; you must file those with your insurance company for reimbursement.
If You Have a Managed Care Contract
I do not participate in any HMO organizations at this time. However, if you belong to a health maintenance
organization (HMO) or have another kind of health insurance with managed care, decisions about what
kind of care you need and how much of it you can receive will be reviewed by the plan. The plan has rules,
limits, and procedures that we should discuss.
If required, I will provide information about you to your insurance company only with your informed and
written consent. I may send this information by mail or by fax. My office will try its best to maintain the
privacy of your records, but I am not responsible for accidents or for anything that happens as a result.
If You Need to Contact Me
I cannot promise that I will be available at all times. I do not take phone calls when I am with a client. You
can always leave a message with my voice mail and I will return your call as soon as I can. Generally, I will
return messages daily except late on Saturdays, most of the day on Sundays, and any holiday.
If you have an emergency or crisis, tell me this in your voice mail. If you have a behavioral or emotional
crisis and cannot reach me immediately by telephone, you or your family members should call 911 or one
of the following Gwinnett community emergency agencies: the crisis center at Summit Ridge Hospital at
678-442-5800 or the Gwinnett Hospital emergency room at 678-442-4357. These phone numbers are
accurate as of December 2007.
If I Need to Contact Someone about You
If there is an emergency during our work together, or I become concerned about your personal safety, I am
required by law and by the rules of my profession to contact someone close to you—perhaps a relative,
spouse, or close friend. I am also required to contact this person, or the authorities, if I become concerned
about your harming someone else. Please write down the name and information of your chosen contact
person in the blanks provided:
Name: ____________________________________________________________
Address: ___________________________________________________________
Phone: ________________________ Relationship to you: ____________________
Other Points
If you ever become involved in a divorce or custody dispute, I want you to understand I cannot provide
expert testimony in court. You should hire a different mental health professional for any evaluations or
testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in
your favor because we have a therapy relationship; and (2) the testimony might affect our therapy
relationship, and I must put this relationship first.
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Doing follow-up and outcome research is always educational. As a professional therapist, I naturally want
to know more about how therapy helps people. To understand therapy better, I may collect information
about clients before, during, and after therapy. Therefore, I may ask you to help me by filling out some
questionnaires about different parts of your life-relationships, changes, concerns, attitudes, and other
areas. I ask your permission to take what you wrote on these questionnaires and what I have in my records
and use it in research or teaching that I may do in the future. If I ever use the information from your
questionnaire, it will always be included with information from many others. Also, your identity will be made
completely anonymous. Your name will never be mentioned, and all personal information will be disguised
and changed. After the research, teaching, or publishing project is completed all the data used will be
destroyed.
If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or
materials, I will return the originals to you at your written request but will retain copies.
Referral Information.
If you have been referred by your doctor, pastor, counselor, or another professional I ask for your
permission to send a letter to them acknowledging the referral and thanking them for doing so. I will not
give them any personal information nor have any other contact with them without your written permission.
I do this just as a professional courtesy. If you decline it will not affect our professional relationship. If you
approve/disapprove please check the appropriate response and initial. __ approve __ disapprove ; ___
Initial. Who referred you? Please give their name, address, and phone # - __________________
_______________________________________________________________________. If you found out
about Greenleaf Counseling through an advertisement please list the source and name (ex.- Yellow pages
ad, website, etc.) ___________________________.
Statement of Principles and Complaint Procedures
It is my intention to fully abide by all the rules of the American Association of Marriage and Family
Therapists (AAMFT) and the Licensed Professional Counselors Association of Georgia (LPCAGA) and by
those of my state license.
Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any
area of our work, please raise your concerns with me at once. Our work together will be slower and harder
if your concerns with me are not worked out. I will make every effort to hear any complaints you have and
to seek solutions to them. If you feel that I, or any other therapist, has treated you unfairly or has even
broken a professional rule, please tell me. You can also contact the state or local counseling association
and speak to the chairperson of the ethics committee. He or she can help clarify your concerns or tell you
how to file a complaint.
In my practice as a therapist, I do not discriminate against clients because of any of these factors: age, sex,
marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical
disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a
personal commitment, as well as being required by federal, state, and local laws and regulations. I will
always take steps to advance and support the values of equal opportunity, human dignity, and
racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter
to my attention immediately.
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Our Agreement
I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature
below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of
my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start formal
therapy. I also understand that any of the points mentioned above can be discussed and may be open to
change. If at any time during the treatment I have questions about any of the subjects discussed in this
document, I can talk with you about them, and you will do your best to answer them.
I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for
any reason. However, I will make every effort to discuss my concerns about my progress with you before
ending therapy with you.
I understand that no specific promises have been made to me by this therapist about the results of
treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary
for therapy to be effective.
I have read, or have had read to me, the issues and points in this information. I have discussed those
points I did not understand, and have had my questions, if any, fully answered. I agree to act according to
the points covered in this document. I hereby agree to enter into therapy with this therapist (or to have the
client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here.
______________________________________________ ____________
Signature of client (or person acting for client) Date
______________________________________________
Printed name
______________________________________________ ____________
Signature of spouse/client (or person acting for client) Date
______________________________________________
Printed name
Relationship to client:
__ Self __ Spouse __ Parent __ Legal guardian
__ Health care custodial parent of a minor (less than 14 years of age)
__ Other person authorized to act on behalf of the client
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To Be Filled Out By the Therapist
I, the therapist, have met with this client (and/or his or her parent or guardian) for a suitable period of time,
and have informed him or her of the issues and points raised in this information. I have responded to all of
his or her questions. I believe this person fully understands the issues, and I find no reason to believe this
person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the
client, as shown by my signature here.
______________________________________________ ____________
Signature of therapist Date
I truly appreciate the chance you have given me to be of professional service to you, and look forward to a
successful relationship with you. If you are satisfied with my services as we proceed, I (like any
professional) would appreciate your referring other people to me who might also be able to make use of my
services.
___ Copy accepted by client ___Copy kept by therapist
