counseling informed consent form

your client with an informed consent document at the first session is mandated by all state Providing counseling boards. To complete this thread, search for ” counseling informed consent form.” Download and read 1 sample of a counselor’s informed consent form professional from a professional counseling agency or a licensed counselor in your state listed from your search. Please choose an informed consent you have not reviewed previously. Compare and contrast the content of the informed consent to:

1.) The recommendations of the ACA Code of Ethics and

2.) Virginia state board rules/regulations.

Also, include your reaction to the informed consent form that you found on the Internet.

**** Please use this informed consent form below****

The following information is to be completed by the person being served or the person’s authorized representative/parent.

The purpose of this document is to inform you, the client, about many aspects of online counseling services: the process, the counseling, the potential risks and benefits of services, safeguards against those risks, and alternatives to online services. Please read this entire document, sign, and return.

A. Process

1) Possible misunderstandings: The client should be aware that misunderstandings are possible with telephone and text-based modalities such as Store and Forward because nonverbal cues are relatively lacking. Even with video webcam software, misunderstandings may occur due to connection problems causing image delays or less than optimal image quality. Counselors are observers of human behavior and gather much information from body language, vocal inflection, eye contact, and other non-verbal cues. If you have never engaged in online counseling before, please have patience with the process and clarify information if you think your counselor has not understood you well. Also, please be patient if your counselor asks for periodic clarification. All sessions and messaging are in English.

2) Turnaround time: Using asynchronous (not in “real time”) communication such as messaging entails a “lag” of response. This is considered Store and Forward. The counselor will make every effort to respond to message requests within a 24-hour period. If the client is in a state of crisis or emergency, the counselor recommends the client contact a crisis line or an agency local to the client. Clients may also utilize 00000000000 (For the deaf or hard-of hearing 00000000000).

3) Privacy of the counselor: Although the internet provides the appearance of anonymity and privacy in counseling, privacy is more of an issue online than in person. Bill Jones, has chosen to use either or as the software provider for web conferencing, and chat communications between the counselor and clients. The client is responsible for securing his or her own computer hardware, internet access points, and password security.

The counselor has a right to his privacy and may wish to restrict the use of any copies or recordings the client makes of their communications. Clients must seek the written permission of the counselor before recording any portion of the session and/or posting any portion of said session on internet websites such as Facebook or YouTube. Counselor can’t become friends with clients on social media, such as Facebook, Twitter, etc.

B. Potential benefits: The potential benefits of receiving mental health services online include both the circumstances in which the counselor considers online mental health services appropriate and the possible advantages of providing those services online. For example, the potential benefits of video sessions include the convenience for clients to potentially receive counseling from anywhere once an internet signal and necessary hardware is secured. Message based Store and Forward has many of the same advantages of convenience, feeling reduced scrutiny from the counselor, having time to compose a response, and being able to refer to the chat log for reference. The benefits of using asynchronous messages may include (1) being able to send and receive message at any time of day or night; (2) never having to leave messages or voicemails; (3) being able to take as long as one likes to compose a message and having the opportunity to reflect upon it; (4) automatically having a record of communication to refer to later; and (5) feeling less inhibited than in person.

C. Potential risks: There are various risks related to electronic provision of counseling services related to the technology used, the distance between counselor and client, and issues related to timeliness. For example, the potential risks of message-based counseling may include (1) messages not being received and (2) confidentiality being breached, lack of password protection or leaving information on a public access computer in a library or internet café. Messages could fail to be received if they are sent to the wrong address (which might also breach of confidentiality) or if they just are not noticed by the counselor. Confidentiality could be breached in transit by hackers or Internet service providers or at either end by others with access to the client’s account or computer. People accessing the internet from public locations such as a library, computer lab, or café should consider the visibility of their screen to people around them. Position yourself to avoid others’ ability to read your screen. Using cell phones can also be risky in that signals are scrambled but rarely encrypted.

D. Safeguards: Your counselor has selected an account with or for messaging and video communications to allow for the highest possible security and confidentiality of the content of your sessions. In order to benefit from these safeguards, the client is required to download, register and utilize the chat and video software from or Your personal information is encrypted and stored on a secure server in compliance with HIPAA regulations. For ease of use, Bill Jones can assist you in downloading or The client is responsible for creating and using additional safeguards when the computer used to access services may be accessed by others, such as creating passwords to use the computer, keeping their email and chat IDs and passwords secret, and maintaining security of their wireless internet access points. The counselor and client will also choose a password in the first session to be exchanged at the beginning of all subsequent distance sessions in order to verify the identity of the client. Please discuss any additional concerns with your counselor early in your first session to develop strategies to limit risk.

E. Alternatives: Online counseling is a non-acute service and may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving mental health services online would be receiving mental health services in person. Bill Jones, LPC can and will assist clients who would like to explore face-to-face options in their area. Please feel free to request a referral at any time you think a different counseling relationship would be more practical or beneficial for you.

F. Proxies: The counselor requires this consent form to be signed by the legal guardian of any client seeking services who is under the age of 18. The name and contact information of the legal guardian will be kept as part of the client’s record.

G. Confidentiality of the client: Maintaining client confidentiality is extremely important to the counselor and the counselor will take ordinary care and consideration to prevent unnecessary disclosure. Information about the client will only be released with his or her express and written permission with the exceptions of the following cases: 1) If the counselor believes that someone is seriously considering and likely to attempt suicide; 2) if the counselor believes that someone intends to assault another person; 3) if the counselor believes someone is engaging or intends to engage in behavior which will expose another person to a potentially life-threatening communicable disease; 4) if a counselor suspects abuse, neglect, or exploitation of a minor or of an incapacitated adult; 5) if a counselor believes that someone’s mental condition leaves the person gravely disabled.

H. Records: The counselor will maintain records of online counseling and/ or consultation services. These records can include reference notes, copies of transcripts of chat and internet communication and session summaries. These records are confidential and will be maintained as required by applicable legal and ethical standards according to the American Counseling Association, National Board of Certified Counselors, the Virginia Board of Clinical Social Workers, Marriage and Family Therapists and Mental Health Counselors. The client will be asked in advance for permission before any audio or video recording would occur on the counselor’s end.

I. Procedures: The counselor might not immediately receive an online communication or might experience a local backup affecting internet connectivity. If the client is in a state of crisis or emergency, the counselor recommends contacting a crisis line or an agency local to the client. Clients may utilize the following crisis hotlines.

J. Payments: All payments will be processed through l. I understand payment of fees is expected at the time of service. Client agrees to pay for each service at the time it is rendered. Client understands they am responsible for all charges incurred, regardless of insurance status. Client will notify Bill at least 48 hours in advance if I am unable to keep my appointment.

K. Disconnection of Services: If there is ever a disruption of services on the internet then the client will need to call Bill Jones, to discuss how to proceed with the session. Bill jones, can be reached at 000-000-000


COUNSELING: My practice is based on an hourly system, and I function on a tight schedule. I begin the hour at the scheduled time, I hold a 50- or 25-minute counseling session. Even when you are late, I will still end on schedule. Individuals are expected to be available by phone during the session in case of an interruption in the teletherapy service.

APPOINTMENTS NOT CANCELLED 48 HOURS PRIOR TO THE MEETING TIME ARE CHARGED. If I can reschedule someone for that time, or I make the cancellation, you will not be charged.


Webcam based Individual, Family or Couples Counseling: $0 – 50 minutes

Phone based Individual Counseling: $ minutes

Two written messages per month; Store and Forward: $

Reports, such as letters, are billed at $

Mental Health Evaluations – $

Emotional-Support-Animals Evaluations: $

Competency to Stand Trial Evaluations: $

PAYMENT IS DUE WHEN SERVICES ARE RENDERED. It is the responsibility of the client to maintain the account up to date to assure continuation of services.


My primary therapy orientation is: Person Centered, Motivational Interviewing, Cognitive Behavioral Therapy, Life-Style design, and Brief-Solution Focused.

I provide services on topics such as: Anxiety, Lifestyle and Adjustments to Challenges in Life, Addictions, Anger Management, Stress Reduction, Couples Counseling, Men’s Issues, and Overall Personal Growth. Teletherapy has been very beneficial for people who have difficulty leaving the home, frequently travel,or have limited mental health resources in their community. Teletherapy has also been beneficial for English speaking people living abroad.

I am seeking services from Bill Jones. The type and extent of services I receive will be determined following a consultation with Josh and me. I will work with Josh to develop a plan designed to assist me in attaining my goals. I understand that this is a collaborative effort between Bill Jones and me.

I understand that I have the freedom to choose to have counseling online by distance-counseling or teletherapy. I understand that there are risks to teletherapy, such as failure in technology or breaches of confidentiality. I understand teletherapy is a non-acute service.

By signing this consent, I agree to abide by its content. I am aware that I have the freedom of choice of providers, and I choose Bill Jones, to provide me with services.

_______________________ ________________________

(Full Name) Signature/Date

If the parent/ guardian are undertaking the financial obligation for services please fill out the following:

I authorize Bill Jones to consult with and undertake the counseling of ____________________ with the appropriate methods or techniques available.

________________________ ________________________

(Full Name) Signature/Date


  • a month ago
  • 11.09.2021
  • 12