Abigail Zandevakili

123 Summer Street, Suite ABC

(508) 555-1234

Client Agreement and Informed Consent

Qualifications: I have an M.Ed. in Mental Health Counseling from Bridgewater State University. I
am Licensed Mental Health Counselor (LMHC) with the state of Massachusetts, and a National
Certified Counselor (NCC).

Clients served: I provide therapy for children, adolescents, and adults. I am experienced in
working with military veterans readjusting to civilian life after military service.

Theoretical approaches: The treatment approaches I primarily use are Cognitive Behavioral
Therapy (CBT) and Cognitive Processing Therapy (CPT). Through CBT, individuals learn how to
identify and change the disturbing and/or destructive thought-patterns negatively influencing
one’s behavior(s). CPT is a specific type of CBT which helps individuals learn to modify and
challenge unhelpful beliefs related to a traumatic event. Through CPT, individuals will begin to
create a new understanding and conceptualization of the traumatic event, reducing negative
effects of one’s current life.

Code of Ethics: I adhere to the Massachusetts Mental Health Counselors Association Code of
Ethics and the American Counseling Association Code of Ethics. Copies of these Codes are
available upon request.

What to expect from therapy: Our sessions together will serve as a space to identify and build
on your current strengths, develop positive coping skills, learn efficient problem-solving
strategies, learn more effective ways to communicate with others, and receive support and
feedback. The overall objective for therapy is always the successful resolution of the problems
deemed most important through a collaborative process between you and I. Additionally, the
goals set in therapy are established through this collaboration. We both have active roles in your
success. I will provide a secure and supportive environment conductive to awareness, healing,
and personal growth. In return, you are expected to actively participate in the counseling
process, give advanced notices of cancellations, inform me of any other ongoing counseling,
and keep me updated of any medication changes. Together, we can help you move towards
obtaining desired goals.

During our first session (intake session), I will gather information about your history, areas of
concern, and any goals that come to mind for treatment. The intake process will be the time to
ask any questions and/or concerns you may have. Over the course of the next several sessions,
there will be opportunities to share your thoughts and feelings, request assistance with specific
issues that arise between sessions, and collaboratively work towards achieving agreed upon
treatment goals. An important aspect of therapy will be practicing new skills and monitoring
certain behaviors and/or thoughts. There may be times you will be asked to complete
“homework” in between sessions, role-playing during sessions, reading and completing
handouts, keeping records, and/or other assignments vital to the therapeutic process. The
completion of these activities is necessary if you are to get the most from the therapeutic
experience.

The length and frequency of our therapy together will be determined by your specific needs and
goals. We will periodically evaluate your satisfaction and progress throughout our time together.
In the later stage of therapy, we will begin to meet less frequently in preparation for termination.
Although you may choose when therapy ends, it high highly recommended and especially
helpful to have at least one session together to summarize the progress and to say goodbye.

Risks and benefits of counseling: Therapy involves discussing aspects of a your life that you
find unpleasant. Risks, such as temporary feelings of sadness, anger, guilt, frustration, loneliness,
and helplessness, may arise. Benefits of counseling include a significant reduction in feelings of
distress, new insights into self, solutions to problem-solving, and improved relationships.
Though there is no guarantee for how the therapeutic process will be for you specifically,
bringing motivation to each session is important to the process.

Alternatives to traditional therapy: Stress management, 12-step programs, bibliotherapy,

support groups, and peer self-help groups.

Minor clients: If you are the parent or guardian and are requesting services for your
child/adolescent under the age of 18, I will need your permission to provide counseling services
to them. Keep in mind while you have the right to question and understand the nature of your
child/adolescent’s sessions, treatment is usually more effective if your child/adolescent has some
privacy. It is therapeutically important your child/adolescent develops a level of trust with me, so
if you agree, I will only provide you with a general overview of each session, along with your
child’s level of participation and progress. However, there are limits to confidentiality (listed
under “Confidentiality and Privilege”).

Fees/Payment: My fee is $100 for 50-minute sessions and $150 for 80-minute sessions.
Payments are due at the time of service, unless we have agreed on other arrangements. I will file
with your insurance company as a courtesy to you. If I am working “in-network”, the fee is
reduced based on my contact with your insurance company. In such cases, your insurance
company will pay a portion of the cost of your therapy per session, and the remainder (co-pay)
will be your responsibility, collected at the time of service. Cash or personal checks are
acceptable for payment.

Appointments, Late Arrival, Cancellation Policy: Appointments are typically set at the close of
each session. If you need to reschedule or cancel an appointment, please contact me as soon as
possible. Your insurance will not pay for missed appointments.
  Appointments cancelled/rescheduled at least 24 hours prior to the session time will not be
charged.
 Appointments cancelled/rescheduled less than 24 hours prior to the session time may
result in a fee for the time reserved for you.
 No-shows will be charged $50. After a second occurrence, I may choose to refuse the
scheduling of future appointments.
 No reduction in fees will result from shortened sessions due to a client’s late arrival
 Frequent cancelling/rescheduling may also result in a refusal of future appointments.

Professional records: The laws and standards of our profession require we keep treatment
records. You are entitled to receive a copy of your records. Because they are professional
records, they can be misinterpreted and/or upsetting to you. I highly recommend reviewing your
records in my presence to discuss its contents, though not necessary. All records include: a
chronological listing of appointments and fees; a copy of signed releases; a copy of all my notes.
All records are maintained by me in a secured area for a period of seven years from the time of
service termination. As a client, you have a right to access your records. You also have the right
to consent to the material in your records, and it will be noted in your record if you do so. You
do not have a right to alter your records or dictate information to be removed. Though you have
the right to access your records, you do not own them.

Diagnosis: If a third-party, such as an insurance company, is paying for part of your bill, I may
be required to give a diagnosis to the third-party in order to be paid. Diagnoses are technical
terms that describe the nature of any presenting problems by an examination of symptoms. If I
do use a diagnosis, it will be discussed with you.

Interruptions in therapy: When I am on vacation or plan to be unavailable for a brief period of

time, I will provide you with the name and number of another therapist you may contact with
any questions or come in to see, as needed. In the event of a longer interruption of therapy, I
will make appropriate referrals in your best interest.

Confidentiality and Privilege: I will not disclose your confidences and information to any third-
party – except for materials shared during supervision – without your written consent or waiver,
except when mandated or permitted by law. Verbal authorization will not be sufficient except in
emergency situations. State law mandates I report to the appropriate authorities suspected
cases of child abuse/neglect, elder abuse/neglect, or disabled abuse/neglect, in addition to
instances of danger to oneself or others when reasonably necessary, to protect you or other
parties from clear and imminent threat of serious physical harm.

I routinely consult with other licensed colleagues regarding cases. In the event I consult about
your case, all identifying information is excluded to protect your confidentiality.

In addition to the above, there are several other situations where confidentiality cannot be
insured, including: 1) If you are a child (under 18 years of age) or unable to voluntarily consent,
a guardian must give written consent and can access your records, 2) If you choose to file
insurance or work with a managed care company, information regarding your treatment,
diagnosis, prognosis, and the specific issue for which you have come to treatment are available
to the insurance or managed care company, 3) If there is payment owed, you will receive a
letter. If payment is not made within two weeks of the letter, your name, address, and amount
owed will be released to a third-party for collections.

Emergency: Our relationship is strictly professional. Contact will be limited to arranged

counseling sessions, except in case of emergency. In the event of any mental health emergency,
you may call the answering service at (123) 098-7654, in which I will get back to you as soon as
possible. In cases of immediate distress, please contact the local 24-hour hotline number at
(098) 123-4567 or 911.

Referrals: Should you and/or I believe a referral is needed, I will provide alternatives, including
programs and/or other professionals, who may be of assistance. It will be your responsibility to
contact and evaluate the referrals and alternatives given to you. At any time, you may initiate a
discussion with me of the possible positive and negative outcomes of entering, not entering,
continuing, or discounting services.

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As the client, your signature below indicates that you have read and fully understand this
document and have been provided with your own copy. All questions have been answered
to your satisfaction, and you recognize that you have the opportunity now, and in the
future, to discuss any questions you may have with me. Your signature constitutes your
agreement and compliance to this document and its contents. We both abide by the
stipulations listed herein.

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Print Client Name Date of Birth

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Signature Today’s Date

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Signature of Parent/Guardian (if applicable) Today’s Date

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Signature of Therapist Today’s Date