We understand that couples therapy begins with an evaluation of our relationship, past and present. While Wendy Pearson, FNP-C LMFT, is deciding whether she is the appropriate therapist for us, we will decide whether we wish to begin couples therapy with her. We understand that because of the commitment of time and money, plus the potential impact on us and others, it is important to make an informed choice for a couple’s therapist.

We have read and understand the potential limits of confidentiality, including those imposed by the Medical Wellness Center of Georgia’s policies and by state law, and we have received a copy to keep. We understand that information discussed in couple’s therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners. We agree not to subpoena Wendy Pearson to testify for or against either party or to provide records in a court action.

We understand all policies as related to appointment cancellation, rescheduling, and no shows: if you do not show for your appointment, cancel, or do not reschedule within 24 hours of your appointment time, you will be billed an administrative fee of $25.00. The patient and/or couple is responsible for all charges of services when rendered. We accept these as conditions for entering couple’s therapy with Wendy Pearson. We understand the limits and benefits of using a cash option to pay for couple’s therapy. We understand that the initial visit will be charged at $125.00 with subsequent follow up appointments agreed upon by the client and will be charged $100.00.

We have been given the opportunity to ask questions and discuss confidentially and disclosure policies with Wendy Pearson. We understand that while working as a couple, what either of us tells Wendy Pearson individually, whether on the phone or in an individual meeting, may not be held as confidential, and at Wendy Pearson’s discretion, may be shared with the spouse/partner during a subsequent couple session.

We agree to share responsibility with Wendy Pearson for the therapy process, including goal setting and termination. By entering couple’s therapy, we accept that we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. We understand that the changes one or both of us make will have an impact on our partner and on others around us. We accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. [This is especially true if we have dependent children.]

By signing below, we agree to accept mental health services from Wendy Pearson, FNPC;LMFT, and accept full responsibility for payment for such services.