Welcome to Peacefully You, LLC. Please take a few minutes to read through this informed consent form to understand more about counseling and get to learn more about the solutions that can address your concerns to get you back on track.

GENERAL INFORMATION  The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information by signing on the last page.

THE THERAPEUTIC PROCESS  You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

CONFIDENTIALITY  The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

RELATIONSHIP  The therapist cannot have any other relationship with the client than a professional one.  The relationship required for effective counseling is strictly professional. 

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.  This is for the best interest of the parties. 

Teletherapy involves the use of electronic communications to enable therapists to see their clients for regular sessions from their home. 

CONSENT FOR TELETHERAPY

1. I understand that my provider wishes me to engage in teletherapy counseling sessions. 

2. I understand video conferencing technology is not the same as a direct client/provider session due to the fact that I will not be in the same room as my provider.

3. I understand that a teletherapy session has potential benefits, including easier access to care and the convenience of meeting from a location of my choosing.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.  I understand that my provider or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.

 

 CONSENT TO USE TELEMEDICINE BY DOXY.ME

1. I hereby authorize Peacefully You, LLC to use a HIPPA approved application (doxy.me) for Teletherapy sessions.

2. Telemedicine by Doxy.me is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

3. The Telemedicine by Doxy.me facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice, or care.

4. I agree that my medical records, from teletherapy, can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

5. To maintain confidentiality, I will not share my teletherapy appointment link with anyone unauthorized to attend the appointment.

 

*Feel free to learn more about Doxy.me on their website.

CONSENT  I understand that this consent is purely voluntary.  I understand that I can withdraw anytime from therapy by informing my therapist. By signing below, I am agreeing that I have read, understood, and agree to the items contained in this document.  I give my consent to the treatment and therapy sessions with the therapist.