Informed Consent for Mental Health Services

1. PURPOSE OF THIS DOCUMENT. The therapeutic relationship is unique in that it is a highly personal and, at the same time, a contractual agreement.This Informed Consent outlines how therapy works, what you can expect, how your privacy is protected, and the responsibilities we both hold. Please read carefully. Your signature confirms that you understand and agree to these terms.

2. THERAPEUTIC PROCESS. You have taken a very positive step by deciding to seek therapy. Therapy is a collaborative process that may bring relief, insight, and meaningful change. Therapy can also involve discomfort, including discussing painful memories and emotions. Progress varies by person. Specific results or outcomes cannot be guaranteed. I will provide skilled, evidence-informed treatment and clear guidance. You are responsible for your level of engagement, effort, and follow-through. Therapy is not a substitute for emergency services, medication management, or a higher level of psychiatric care when needed.

3. THERAPIST ROLE AND BOUNDARIES. To maintain a professional and effective therapeutic relationship:

  • I will use self-disclosure only when therapeutically appropriate.

  • I do not accept gifts.

  • I do not engage in personal, social, romantic, financial, or business relationships with clients.

  • I do not connect on personal social media accounts.

  • Communication occurs primarily through the secure Client Portal.

I do not provide forensic, evaluative, or expert witness services, including custody evaluations, disability determinations, or court-related recommendations. If I am subpoenaed, court-ordered, or otherwise legally required to participate in legal proceedings, fees for preparation, consultation, and testimony will apply as outlined in the Good Faith Estimate.

This practice requires consent to AI-assisted audio recording for clinical documentation as a condition of receiving services. This is further detailed in the Use of AI Tools Informed Consent.

If it is assessed that therapy is being used for non-therapeutic purposes (e.g., legal positioning, manipulation, or third-party agendas), I may discontinue treatment. Please remember that therapy is not guaranteed to produce specific results. Due to the nature of therapy being a rendered service (verses a tangible product), refunds will not be given for any sessions already held.

4. CLIENT RESPONSIBILITIES.

  • Be physically in the state of New York when joining a telehealth session.

  • Arrive on time for all scheduled appointments.

  • Attend sessions sober. If you attend a session under the influence of a substance, the session may be terminated, and you will be responsible for the full session cost.

  • Maintain updated contact information for yourself and your assigned emergency contact.

  • Participate in treatment.

  • Keep personal environment confidential when joining a telehealth session.

  • Pay any balances on time.

5. CONFIDENTIALITY. Everything shared through our work during the therapeutic process is confidential except in situations where I am legally or ethically required to act to protect safety. Situations include:

  • Client is in immediate risk of suicide or serious self-harm.

  • Client threatens harm toward another person.

  • Any serious medical or safety concerns where emergency services must be contacted.

  • Therapist has a reasonable suspicion that a client is the victim, perpetrator, or observer of neglect, physical, emotional, or sexual abuse of a vulnerable person. ‘Vulnerable Person’ refers to children under 18 and/or dependent adults/elders, as defined by state law.

  • Therapist receives a court order or a lawful subpoena. If a subpoena is received, Therapist will make every effort to contact you before responding to it.

  • Client is being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

  • Consultation with other professionals (your identifying information is not shared).

  • Accidental contact between Client and Therapist out in public (note that Therapist will never initiate an interaction when in public in an effort to best protect Client’s privacy).

  • For minor clients, your parents may be entitled to some information. You will be made aware of any information shared with your parents.

6. EMERGENCY / RISK MANAGEMENT REQUIREMENTS. Therapy is not a crisis service. I do not provide crisis services. I cannot guarantee I will be available to provide support outside of your scheduled session time. Messages received outside of business hours will be addressed on the next business day. If you are in immediate danger, call 911 or go to the nearest Emergency Room. If you need crisis support for thoughts of suicide, you can call or text 988 for the National Crisis Hotline 24/7. For your safety, you agree to:

  • Provide me with an up-to-date emergency contact to have on file.

  • Inform me of your current location at the beginning of each telehealth session.

  • Allow me to contact your emergency contact or emergency services if I believe you are at risk.

  • Reconnect if we get disconnected during a telehealth session. If we get disconnected, I will attempt to reconnect with you for five (5) minutes. If we are unable to resume a video feed, you agree:

    • to pick up if I call.

    • If text is your only viable communication due to a technology failure, you agree to communicate with me via text to confirm your safety.

    • Text messaging is not for therapeutic support or crisis communication. If you are unsafe, and we’ve been disconnected, you agree to call 911.

    • If we are unable to resume a connection and I am concerned for your safety, I may contact emergency services.

7. SCOPE OF PRACTICE. I provide individual mental health counseling. I do not provide the following services:

  • Psychological testing

  • Custody evaluations

  • Fitness-for-duty evaluations

  • Emotional support animal letters

  • Disability determination letters

  • Court-related recommendations

8. TERMINATION OF SERVICES. Ending a therapeutic relationship can feel difficult, and a thoughtful termination process supports closure and continuity of care. When possible, a final session is recommended to review progress, identify remaining needs, and create a plan for moving forward.

Therapy may be concluded for any of the following reasons:

  1. Client-Requested Termination. You may end therapy at any time. A final session is encouraged, but not required, to provide closure and discuss next steps or referrals.

  2. Inactivity / Failure to Attend Sessions. If you do not schedule or attend an appointment for four (4) consecutive weeks and there has been no communication or documented plan to continue treatment,

    • the therapeutic relationship will be considered discontinued for legal and ethical reasons.

      • A documented plan may include a scheduled future appointment or a written agreement regarding a temporary pause in treatment.

      • Financial agreements, including the Fee Reduction Agreement, do not replace the requirement for clinical communication or an active plan of care.

      • You may request to return to therapy at a later time; however, availability cannot be guaranteed.

  3. Nonpayment or Outstanding Balances. Services may be paused or discontinued if you are in default on payment or if an outstanding balance remains unpaid. Payment issues must be resolved before scheduling future sessions.

  4. Misuse of Therapy. Therapy is for personal mental health treatment. Services may be terminated if therapy is being used for non-therapeutic purposes, including:

    • legal positioning or leverage

    • attempts to obtain letters or documentation outside the scope of practic

    • seeking support for third-party agendas

    • behaviors that compromise therapeutic neutrality