Sample Informed Concent

Consent Form
Leslie Valerio, Cynthia Barnes, Christina Wood, Ranisha Sloan, Reyna Rosales
MFCC/551 Legal and Ethical Issues in Marriage and Family Therapy
August 7, 2014
Rosemary Botch, MFT

Learning Team A: A Better Way
Licensed Marriage, Family and Child Therapists


Welcome to my practice. This document contains important information about the professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

Therapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Therapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.
Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress but there are no guarantees of what you will experience.

MEETINGS _______ (Initials)
I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. I will usually schedule one 50-minute session per week at a time we agree on. You are responsible...