Informed Consent
Hello, and welcome to therapy. I’m glad you’re here, and I’m looking forward to working with you. This agreement covers what you can expect from our work together, along with your rights and protections. Please take a moment to read through it.
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Therapy is a collaborative process where we work together to help you gain insight, grow personally, and improve in areas that are important to you—whether that’s in your thoughts, emotions, or behaviors. The goal is to enhance your mental and emotional well-being, reduce symptoms of emotional or behavioral challenges, and empower you to live a more fulfilling life. Throughout our time together, we’ll focus on fostering positive changes that support your overall well-being.
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Limits of Confidentiality
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Your privacy is important, and I want to assure you that your personal information won’t be shared without your explicit permission. Everything we discuss is confidential, with a few exceptions: if there’s talk of harm to others, self-harm or suicidal ideation, elder abuse, child abuse, or dependent adult abuse, I may need to contact the appropriate authorities. Also, if you’re involved in a legal case, I could be required to share information about your treatment.
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Please note that communication via email or text may not be fully confidential.
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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:
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If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
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If a client threatens grave bodily harm or death to another person.
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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.
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Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
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Suspected neglect of the parties named in items #3 and # 4.
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If a court of law issues a legitimate subpoena for information stated on the subpoena.
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If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
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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.
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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 document between ________ (client) and Jake Rose serves as a written agreement, showing that you understand we’re entering into a therapeutic relationship with clearly defined roles: Therapist and Client.
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Payment
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The fee for a 60-minute session is $225, payable upon receiving the invoice, unless we’ve made other arrangements. The frequency of our sessions can vary, from multiple times a week to once a month, depending on your needs.
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If you ever want to extend a session beyond the standard 60 minutes, we can certainly do that. Just keep in mind that any extra time will be billed in 5-minute increments, including extended phone conversations.
For those who prefer in-person sessions at a location other than my office, I’m happy to accommodate. Please be aware that travel time from my office will be factored into the billing. For every 30 minutes of driving time, an additional 10 minutes will be added to your invoice.
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As an out-of-network provider, I don’t process insurance claims directly. However, I can provide you with a superbill that details the services rendered, which you can submit to your insurance company for potential reimbursement.
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Cancellation & Rescheduling
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I understand that life happens, and sometimes things come up. If you’re running late, please know that you’re still responsible for paying for the full session.
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There’s a 24-hour cancellation policy. If you need to cancel a session within 24 hours of our scheduled time, the full session fee will still apply. This policy helps ensure that the time I’ve set aside for you is used effectively.
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If you need to reschedule, please let me know as soon as possible, ideally before the 24-hour window. I’ll do my best to accommodate you, though it’s not always possible. If you have a true emergency that couldn’t be foreseen—like a sudden illness or accident—let’s discuss it.
However, if emergencies start happening frequently, we’ll need to have a conversation about it.
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Risks and Benefits
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Therapy can be incredibly rewarding, but it’s important to know that it may also bring up some uncomfortable feelings as we work through difficult issues. Despite these challenges, the benefits often include improved mental and emotional health, stronger relationships, and increased self-awareness, leading to greater peace of mind and a stronger sense of self.
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Risks and Benefits of Couples Therapy
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Couples therapy, like individual therapy, has its own set of potential benefits and challenges. It can help you and your partner communicate better, understand each other’s needs, and strengthen your emotional connection. It’s an opportunity to resolve conflicts, rebuild trust, and deepen your intimacy, which can lead to a more satisfying and stable relationship.
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However, discussing sensitive issues might be uncomfortable, and therapy could temporarily bring up conflicts or unresolved issues. While the goal is always to move toward a healthier and more fulfilling relationship, therapy can’t guarantee that separation or divorce will be avoided.
Between Sessions
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I’m available for light texting between sessions or a quick phone call of up to 10 minutes if something comes up. If we need to talk longer, I’ll invoice you for the extra time.
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Specialized Services
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With my background in fitness, nutrition, and coaching, I offer these services as part of therapy if they’re something you’re interested in. Here are a few things to keep in mind:
1. Therapy with me may include physical activities or exercise, which carry a risk of injury. You acknowledge and agree that any injury sustained during these activities is your responsibility, including any medical expenses.
2. It’s important to let me know about any previous injuries that could affect your ability to participate in physical activities during our sessions.
3. I may offer hiking, sports, weightlifting, and other forms of exercise as part of therapy. These activities might require physical adjustments to your form or technique. You’re always welcome to refuse physical touch at any time during these sessions.
Voluntary Participation
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Your participation in therapy is entirely voluntary, and you’re free to end our work together at any time.