Consent for Treatment

am indicating that I agree to participate in the following services with Delight J. Renken, LPC-S.  These services may include any of the following:  Individual Therapy, Couples/Family Therapy,  Group Therapy, Clinical Assessment

I understand that, in order to develop the therapist-client relationship and treatment plan necessary to meet my needs, an initial assessment will be completed and a joint decision made to either proceed with the recommended treatment plan or to continue the assessment over additional visits.  The limitations and benefits of all therapy or services I may receive will be discussed with me.  I understand that while the longterm goal of therapy is to feel better, I may experience a period of feeling worse before I begin to feel better and I understand that there is no guarantee of success.  I understand that there may be alternative methods of therapy for my consideration and I am encouraged to ask questions regarding my therapy or other methods at any time.

PRIVACY (CONFIDENTIALITY) POLICY

State and Federal laws protect the confidential nature of the therapist-client relationship. Clinical information will not be released to anyone without prior written consent to do so by client (or the guardian-parent of a minor).  However, there are some exceptions where formation may be released without client consent.

These include:

1. A therapist must take appropriate action when there is a danger to the client or another individual at the client’s hands.  In general, this means that the therapist may involve others to protect the client if he or she is suicidal or unable to provide self-care at a level necessary for basic survival.  Others may be involved to prevent harm to another person.  State law mandates that suspected neglect or abuse of a child, of an elderly individual, or of a disabled individual must be reported.
2. When ordered by a court to do so, a therapist may testify or release client records.  However, no release of information or testimony is given in response to a subpoena without the client’s or client guardian’s written authorization unless required by law to do so.
3. Consultation with other health care professionals may be necessary at some point in time.  Where possible, identification of clients is withheld.  However, there are times when exchange of information is necessary.  An example of this type of exchange would be when a therapist is out of town or on vacation and another therapist is providing coverage for that therapist.  Case material is often used for training, for research, and for other academic endeavors but client identification is always removed.  Any other releases of information must come with the above listed written approval.

I understand that this agreement is valid for the duration of time that I am participating in services with Delight J. Renken, LPC-S (hereinafter referred to as DJR). 

By signing below, I acknowledge that I have received a copy of CONSENT FOR TREATMENT and the PRIVACY (CONFIDENTIALITY) POLICY and I understand and agree to the entire contents of those documents.

I acknowledge that I have had an opportunity to answer any questions, comments, or concerns that I might have prior to signing this consent and participating in services.

I am aware that I can stop counseling at any time.  DJR reserves the right to amend the CONSENT FOR TREATMENT and the PRIVACY (CONFIDENTIALITY) POLICY and changes will be made available at the office of DJR.

I can request a copy of changes at any time at no charge.

Any changes that DJR makes are effective immediately unless otherwise indicated.

A COPY OF THIS PAGE IS ATTACHED FOR YOU.