Karin Elise Weber, LCSW, PLLC

1936 William Street

Fredericksburg, VA, 22401

Phone: (540) 455-4714

Fax: (540) 371-5715

Website: www.kweberlcsw.com

Email: karin@kweberlcsw.com

 

Informed Consent for Counseling Services
Thank you for choosing Karin Elise Weber, LCSW, PLLC for your counseling needs. I, Karin Elise Weber, LCSW, understand that agreeing to counseling is a big step for many people, and that it is important to create a healthy relationship with the client in order to facilitate desired changes. The information that follows is provided to answer any questions or concerns that you may have.

Identifying Information:
The practice of Karin Elise Weber, LCSW, PLLC is located at 1936 William Street in Fredericksburg, Virginia 22401. I (Karin Elise Weber, LCSW) am a professional and skilled in a variety of counseling and assessment specialties.

I can be reached at 540-455-4714 during my hours of operation Monday 12-7, Tuesday 10-5, Wednesday 12-9, Thursday 10-6 and Friday 12-5:30.

Confidentiality:
What you talk about during a session is confidential with exceptions as listed below.

Due to state law there is some information that will be released:

1. If you threaten to harm or kill yourself or another person, I am legally and ethically required to take action for the protection of the threatened party. Actions may include informing the threatened party, requesting your hospitalization, notifying your family or support group, and/or calling 911 for assistance.
2. If I learn of or suspect abuse or neglect of a child, a disabled person, or an elderly person I am mandated to report to the Department of Social Services.
3. If I am involved in any legal action the law mandates that I may be obligated to reveal some information that would otherwise be considered as confidential.
4. If I am ordered by a court to share records, I will first offer a treatment summary. If actual records are required I will obtain a release from you prior to sharing.

Please also be aware that insurance companies require the therapist to disclose some information in order to authorize treatment, including some diagnostic information. This could be prior to and including the first session or from further sessions in order to authorize continued treatment.

If you are experiencing a life threatening emergency please call 911 or go to your nearest Emergency Room. Your safety and health are of the utmost importance to me.

I check my business e-mail and voicemail frequently and return correspondence at the earliest opportunity.

I have read and understood the information on this form, and voluntarily agree to participate in counseling, OR consent to participation of my child in counseling.