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 CLIENT RIGHTS AND RESPONSIBILITIES
This form is designed to inform you on agency policies and ethical issues. Please address any questions or concerns after reading this document with your counselor.
DESCRIPTION OF SERVICES
This agency is privately run and provides services to a variety of needs concerning the psychological well-being of individuals and couples. All persons are eligible for service regardless of race, color, age, sex, sexual orientation, disability, religion, creed, or national origin.
The goal of these services is to help clients identify, assess, and treat problems of concern. The services and counselors are supervised by a licensed experience professional who oversee the quality of work to ensure appropriate services are being delivered.
INFORMED CONSENT
You have the right to be informed about your services, any risk it might entail, and to be involved in developing a plan and what alternatives that might be considered. You have the right to request or refuse any particular approach, to end service, and to be informed about the possible time frames in which the work plan may require. The progress of the work will be reviewed on a monthly basis or more if desired and new goals or approaches may be recommended or discussed. Your written consent will be requested when it is necessary to discuss confidential information with others for the reason of delivering the best possible service to you.
The services offered by this agency have helped many individuals and couples, but there is never a guarantee of success. There are some risks to seeking help and making changes and it is important that you are fully informed of risk. As problems are faced, identified, and discovered, they may seem to get worse before getting better. We work together to identify problems and come up with solutions, and as a result, new ways of thinking and prioritizing may create tension and conflict with others in your relationships. We will try to limit these risks and help you be aware of them as they arise. We believe that making changes are worth the risk, but there may be other risks that are unknown. Please discuss any risks that may come up with your counselor since you must be the judge of how benefits and risks affect you.
PRIVACY AND CONFIDENTIALITY
Confidentiality means that it is necessary to obtain written consent to acknowledge to someone outside this relationship that you are receiving services. As with other agencies, information about your case may need to be discussed with a supervisor within the agency to insure the best quality of care. All documentation and records regarding your case will be kept in a locked file. Because of an obligation to protect you and other members of society from harm, there are the circumstances when confidentiality may be limited:
• If you report a plan of clear and present danger to someone’s welfare (suicide or homicide)
• If you report that a minor or elderly person is being abused or neglected.
• If a medical emergency occurs, and our counselors are contacted, just the relevant information is released.
• Under court order records may be requested or subpoenaed
• If you plan to take legal action against this agency
• If a client is a minor, both custodial and non-custodial parents have access to records.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS AND HAVE BEEN GIVEN THE OPPORTUNITY TO REVIEW THIS DOCUMENT FULLY. I GIVE MY INFORMED CONSENT TO SERVICES AS WILL BE DISCUSSED BETWEEN MY COUNSELOR AND MYSELF.
 
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