Moore Consent Form

Content of the Informed Consent

(See also Corey et al pp. 154-166)

· Goals of therapy

· Services counselor will provide

· What is expected of the client

· Risks and benefits of therapy

· Academic and professional qualifications of the provider

· Financial considerations - should be in line with area. Payment at time of meeting? Billed? Informed about expected payments?

· Expected duration of therapy

· Limitations of confidentiality

· Occasions referral may be needed

· Situations of mandatory reporting

· Any supervisory or consulting arrangements

· No guarantees

· Counselor approach(es) and qualifications to do so (e.g., systems approach – licensed as a MFT)

· How to access ethical guidelines and report malpractice

· Necessary reporting for insurance

· Cancellation of appointment policy

· Emergency contact information

· Accessibility of client records and their storage

· Arrangements in case of counselor being unavailable due to vacation, illness or death

· Statement to sign and date giving consent

Content of the Informed Consent

(See also Corey et al pp. 154-166)

· Goals of therapy

· Services counselor will provide

· What is expected of the client

· Risks and benefits of therapy

· Academic and professional qualifications of the provider

· Financial considerations - should be in line with area. Payment at time of meeting? Billed? Informed about expected payments?

· Expected duration of therapy

· Limitations of confidentiality

· Occasions referral may be needed

· Situations of mandatory reporting

· Any supervisory or consulting arrangements

· No guarantees

· Counselor approach(es) and qualifications to do so (e.g., systems approach – licensed as a MFT)

· How to access ethical guidelines and report malpractice

· Necessary reporting for insurance

· Cancellation of appointment policy

· Emergency contact information

· Accessibility of client records and their storage

· Arrangements in case of counselor being unavailable due to vacation, illness or death

· Statement to sign and date giving consent