Professional Counselling Informed Consent Form

Professional Counselling Informed Consent Form
The Counselling Clinic
We are a counselling service specializing in various counselling. We value our relationship with our clients and believe that such relationship is the beacon in the healing process.
We believe that each individual is unique and has his own way of addressing resolutions. Thus, we believe in a wellness model that helps our clients empower themselves by focusing on what works for them and not in a systematic approach that provides a generic procedure on working on a treatment. One's journey is not the same as the other.
Client's Rights
1. The client may ask questions on what to expect during and end result of the therapy.
2. The client may decline to proceed the therapy as to the techniques which may be conducted by the therapist.
3. The client may cease to continue therapy anytime, without any impediment and may return to therapy anytime.
4. The therapist has the right to dismiss the client from the course of therapy.
5. The client has the right to review his or her records from the therapist.
6. Right to confidentiality: Within limits provided for by law, all records and information acquired by the therapist shall be kept strictly confidential in accordance to the principles of a doctor-patient relationship. All information will not be shared or revealed to any person, agency, or organization without the prior written consent of the client. Although according to the harm principle, if there is a situation where there is domestic violence, self harm or harm for others, therapist has the right to contact the necessary institutions.
7. Referrals: If client has a particular concern needing a specialized treatment approach (e.g. a couples therapy, EMDR therapy, family therapy, sex therapy, alcohol or drug problems specialist etc.), therapist has the right to refer the client to an other specialist in the field.
8. Consultation: Anonymous supervision will be carried out with therapist's supervisor.
9. The client can raise any concerns and to speak with the therapist immediately of any concerns provided that the therapist is likewise available to discuss matters with the client.
Please check the items that you believe is affecting you
Anger or hostile feelingsAnxiety and fearsSadness or Low MoodFamily issuesProcrastinationPhysical distressRelationship/marital concernsShynessTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStress and nervousnessSleep disorderSelf-controlSelf-esteem or confidenceWork or career concernsSexual Concerns
Acknowledgement
I have reviewed this Professional Counseling Informed Consent Agreement. I likewise understand my Client's Rights set in this form.
I accept this agreement and consent to counseling.
Client Name
First NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
GP Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Client Signature
Clear
Date Signed
DayMonthYear
Date
Emergency Contacts
Who to contact in an emergency, step by step

1. First, contact your GP
They are your first port of call if you are feeling worse, both physically and mentally, or if you feel you require medication or need to change your medication.
2. If your GP practice is closed, then contact Crisis Line
This is a telephone helpline when you are unable to contact your GP out of hours.
Tel: 0800 028 8000 (Mon-Fri, 5pm-9am; Sat, Sun & Bank Holiday, 24 hours)

3. 111 (NHS out of hours non-emergency service) for practical support if you are worried about hurting yourself

4. Go to Accident & Emergency if you need immediate help
If you feel absolutely desperate and feel you are at immediate risk either from yourself or others, then go to A&E or ring 999.
The Samaritans – National
Offers confidential non-judgemental emotional support, 24 hours a day, for people who are experiencing feelings of distress or despair, including those which could lead to suicide.
Tel: 08457 90 90 90
Free helpline number: 116 123. Calls to this helpline number do not appear on phone bills.
Email: jo@samaritans.org (responses within 12 hours)
Letter: Chris, P.O. Box 90 90, Stirling, FK8 2SA
The Samaritans
Tel: 0330 094 5717 at any time or email jo@samaritans.org.
Saneline
Offer specialist emotional support and information to anyone affected by mental health difficulties, including family, friends and carers.
Tel: 0845 767 8000 (Every Evening, 6pm – 11pm)
Email Support: www.sane.org.uk
Support Forum: www.sane.org.uk
Mind
Their Infoline provides an information and signposting service. They're open 9am to 6pm, Monday to Friday (except for bank holidays).
Tel: 0208 215 2243
Email Support: supporterrelations@mind.org.uk
Helplines
Infoline: 0300 123 3393
Email Support: info@mind.org.uk
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