Informed Consent Document Template

  Informed Consent Document Template Introduction This document serves as an informed consent agreement between the client and the counselor, outlining the terms and conditions of our therapeutic relationship. Please read this document carefully and feel free to ask any questions or seek clarification before proceeding with counseling services. Counselor Information - Name: [Counselor's Name] - License Number: [License Number] - Contact Information: [Phone Number, Email Address] Client Information - Name: [Client's Name] - Date of Birth: [Client's Date of Birth] - Address: [Client's Address] - Phone Number: [Client's Phone Number] - Email Address: [Client's Email Address] Counseling Services - The counselor agrees to provide counseling services to the client in a professional and ethical manner. - The client understands that counseling is a collaborative process and agrees to actively participate in sessions. - The counselor will maintain confidentiality except in cases where there is risk of harm to the client or others, as required by law. Fees and Payment - The client agrees to pay the agreed-upon fees for counseling services. - Payment is due at the time of service unless other arrangements have been made. - The counselor reserves the right to adjust fees with advance notice. Cancellation Policy - The client agrees to provide at least 24 hours' notice for any cancellations or rescheduling of appointments. - Missed appointments or late cancellations may be subject to a fee. Confidentiality - The counselor will maintain the confidentiality of all information shared during counseling sessions, except in cases where disclosure is required by law. - The client understands that confidentiality does not apply in situations where there is risk of harm to the client or others. Boundaries and Limits of Confidentiality - The counselor will discuss the limits of confidentiality with the client, including situations where confidentiality may be breached. - The client agrees to respect the boundaries set by the counselor and to communicate openly about any concerns or questions. Acknowledgement I have read and understand the terms outlined in this Informed Consent Document. I agree to participate in counseling services with the understanding that this document serves as a foundation for our therapeutic relationship. Client's Signature: _________________________ Date: _________________________ Counselor's Signature: ________________________ Date: ________________________ By signing this document, both the client and the counselor acknowledge their agreement to the terms and conditions outlined herein. This Informed Consent Document is designed to ensure transparency, protection, and clarity in the client-counselor relationship. It establishes a framework for collaboration, communication, and ethical practice, promoting a safe and supportive environment for counseling services.    

Sample Answer