Informed Consent for Psychotherapy Services – Center for Wellness International

Effective Date: June 3, 2025

Welcome to the Center for Wellness International. This document is designed to inform you about our psychotherapy services, your rights as a client, and our professional policies. It is important that you read this document carefully and discuss any questions you may have with your therapist before signing. Your signature below indicates that you understand and agree to the terms outlined.

1. About Psychotherapy

Psychotherapy (also referred to as therapy or counseling) is a collaborative process between a therapist and a client. It is intended to help individuals, couples, or families address emotional, behavioral, and mental health concerns. The goals of therapy vary depending on individual needs and may include improving coping skills, resolving conflicts, reducing symptoms of distress, improving relationships, and promoting personal growth.

There are many different approaches to psychotherapy. Your therapist will discuss their specific approach and the proposed treatment plan with you. Therapy may involve discussing sensitive personal information, exploring difficult emotions, and trying new behaviors.

Benefits and Risks:

• Potential Benefits: Psychotherapy has been shown to have many benefits, including improved mood, reduced anxiety, better relationships, increased self-awareness, and enhanced problem-solving abilities.
• Potential Risks: While benefits are anticipated, therapy also has potential risks. You may experience uncomfortable feelings (such as sadness, guilt, anger, or frustration), recall unpleasant memories, or find that your relationships change. Progress in therapy is not always linear, and symptoms may temporarily worsen before they improve. It is important to discuss any discomfort or concerns with your therapist.

2. Therapist Qualifications and Approach

Your therapist is a [e.g., Licensed Clinical Social Worker, Licensed Professional Counselor, Licensed Marriage and Family Therapist, Licensed Psychologist] in the State of North Carolina. Information about your therapist’s specific training, credentials, and therapeutic approach will be provided to you. You have the right to ask questions about your therapist’s qualifications and experience at any time.

3. Confidentiality

Your privacy and confidentiality are very important to us. Information disclosed by you during therapy sessions is generally confidential and will not be released to any third party without your written consent, except under certain circumstances as required or permitted by law. These exceptions include, but are not limited to:

• Risk of Harm to Self or Others: If your therapist believes you pose an imminent danger to yourself or others, they are ethically and legally obligated to take steps to prevent harm, which may include notifying potential victims, law enforcement, or family members.
• Suspected Child Abuse or Neglect: If your therapist has reasonable suspicion of child abuse or neglect, they are legally required to report this to the appropriate authorities (e.g., Department of Social Services).
• Suspected Elder or Dependent Adult Abuse or Neglect: If your therapist has reasonable suspicion of abuse or neglect of an elderly person or a dependent adult, they are legally required to report this to the appropriate authorities.
• Court Order or Subpoena: If your records are subpoenaed by a court of law, your therapist may be legally required to disclose information.
• Public Health: As required by law for certain public health activities.
• Professional Consultation: Your therapist may consult with other professionals within the Center for Wellness International or with outside supervisors/colleagues to enhance the quality of your care. In these consultations, your identity will be protected, and only necessary information will be shared.
• Insurance/Payment: If you use insurance to pay for services, we will need to share certain information (e.g., diagnoses, dates of service) with your insurance company to process claims.

You will be informed if there is a need to break confidentiality under these circumstances, if feasible and appropriate. A more detailed explanation of our confidentiality practices is available in our Privacy Policy.

4. Appointments and Cancellations

• Session Length: Therapy sessions are typically [e.g., 45-50 minutes] in length, unless otherwise arranged.
• Frequency: The frequency of sessions will be determined collaboratively between you and your therapist based on your needs and treatment goals.
• Cancellation Policy: We require at least [e.g., 24 hours, 48 hours] advance notice if you need to cancel or reschedule an appointment.
  • Cancellations made with less than [e.g., 24 hours] notice may be subject to a late cancellation fee of [e.g., $XX or % of session fee].
  • If you miss a scheduled appointment without providing any prior notice (no-show), you may be charged the full session fee.
  • Insurance companies typically do not reimburse for missed appointments or late cancellation fees.

5. Fees and Payment

• Service Fees: Our current fees for services will be discussed with you. You will be provided with a fee schedule. Payment is due at the time of service unless other arrangements have been made.
• Insurance: If you plan to use insurance, it is your responsibility to understand your benefits, including co-payments, deductibles, and any pre-authorization requirements. We will assist you with information needed for claims, but you are ultimately responsible for the full fee if your insurance does not cover the services.
• Accepted Payment Methods: We accept [List accepted payment methods, e.g., cash, check, credit/debit cards].
• A more detailed explanation of our fee and payment policies is available in our Terms and Conditions.

6. TeleMental Health Services (If Applicable)

If you are receiving services via TeleMental Health (e.g., video conferencing, phone), the following additional points apply:

• Technology: You are responsible for having a reliable internet connection, a suitable device (computer, tablet, smartphone with camera and microphone), and a private, secure location for sessions.
• Security and Privacy: While we use HIPAA-compliant platforms for TeleMental Health, there are inherent privacy risks with electronic communication. We will discuss these with you. It is important to take precautions on your end (e.g., using a secure internet connection, ensuring privacy in your location).
• Emergency Protocol: We will establish an emergency plan, including identifying a local contact person and emergency services in your area, as services are provided remotely.
• Identity Verification: We may use methods to verify your identity at the beginning of each session.
• Technical Difficulties: If technical difficulties interrupt a session, your therapist will attempt to reconnect. If reconnection is not possible, your therapist will contact you to reschedule or make alternative arrangements.
• Appropriateness: TeleMental Health may not be appropriate for all clients or all conditions. Your therapist will assess its suitability for you.

7. Client Rights

As a client, you have the right to:

• Be treated with respect and dignity.
• Receive competent and professional services.
• Actively participate in decisions regarding your treatment plan.
• Ask questions about your therapy and receive clear answers.
• Refuse any recommended treatment or part of a treatment plan.
• Request a second opinion from another therapist.
• Terminate therapy at any time (though we encourage discussing this with your therapist).
• Confidentiality, within the limits described in Section 3 and our Privacy Policy.
• Access your clinical records in accordance with applicable laws and our policies.
• Receive information about the potential benefits and risks of therapy.
• Be free from discrimination based on race, ethnicity, gender, religion, sexual orientation, age, disability, or any other protected status.
• File a grievance if you are dissatisfied with the services received (see our Grievance Policy or discuss with your therapist).

8. Communication Between Sessions

Your therapist will discuss their policy regarding communication between scheduled sessions (e.g., phone calls, emails). Non-emergency communication may be limited. Email and text messaging are not secure forms of communication for confidential information and should be used with caution and primarily for scheduling or administrative purposes. Our services are not intended for emergency crisis intervention. If you are experiencing a crisis or a life-threatening emergency, please call 911 or go to your nearest emergency room.

9. Termination of Therapy

You have the right to terminate therapy at any time. Ideally, termination is a collaborative process discussed with your therapist to allow for a review of progress and planning for future needs. Your therapist also has the right to terminate therapy under certain circumstances, such as if your needs are beyond their scope of practice, if you are not benefiting from therapy, or if there are persistent issues with attendance or payment. In such cases, your therapist will discuss the reasons with you and provide appropriate referrals.

10. Consent to Treatment

By signing below, I acknowledge that:

• I have read and understood the information provided in this Informed Consent for Psychotherapy Services document.
• I have had the opportunity to ask questions about this document and my proposed treatment, and my questions have been answered to my satisfaction.
• I understand the benefits and risks of psychotherapy.
• I understand the policies regarding confidentiality, fees, appointments, and cancellations.
• If applicable, I understand the additional considerations for TeleMental Health services.
• I voluntarily consent to receive psychotherapy services from the Center for Wellness International.
• I understand that I can withdraw my consent at any time by notifying my therapist.

Client Signature (or Parent/Guardian Signature if client is a minor)

Printed Name

Date

Therapist Signature

Printed Name

Date

If client is a minor (under 18 years of age in North Carolina, with some exceptions for consenting to own mental health treatment):

I, the undersigned parent or legal guardian of ____________________________ (Minor’s Name), a minor, do hereby consent to their participation in psychotherapy services with the Center for Wellness International as described in this document. I acknowledge that I have read and understood this Informed Consent document.

Parent/Legal Guardian Signature

Printed Name

Relationship to Minor

Date

Note to the Center for Wellness International:

• Fill in bracketed information (e.g., therapist’s license type, session length, cancellation notice period and fees, accepted payment methods).
• Review with Legal Counsel: This is a template. It’s essential to have it reviewed by an attorney familiar with North Carolina mental health law, HIPAA, and any specific regulations pertinent to your practice to ensure full compliance.
• Adapt for Specific Services: If you offer specialized services (e.g., group therapy, psychological testing), you may need additional consent forms or addenda.
• Minor Consent: North Carolina law has specific provisions regarding a minor’s ability to consent to their own mental health treatment in certain situations (e.g., N.C. Gen. Stat. § 90-21.5). Ensure your policies and practices align with these laws. This template includes a section for parental/guardian consent but be aware of these nuances.
• Provide a Copy: Clients should always receive a copy of the signed Informed Consent document for their records.
• Regular Review: Periodically review and update this document as needed to reflect changes in laws, regulations, or your practi