Adult Informed Consent for Therapy
Privacy of Information Shared in Counseling:
Your Rights and My Policies
THERAPIST-CLIENT SERVICE AGREEMENT
Welcome to my practice. This document contains important information about my
professional services and business policies. It also contains summary information about
the Health Insurance Portability and Accountability Act (HIPAA), a federal law that
provides privacy protections and patient rights about the use and disclosure of your
Protected Health Information (PHI) for the purposes of treatment, payment, and health
care operations. Although these documents are long and sometimes complex, it is very
important that you understand them. When you sign this document, it will also represent
an agreement between us. We can discuss any questions you have when you sign
them or at any time in the future.
THERAPY SERVICES
Therapy is a relationship between people that works in part because of clearly defined
rights and responsibilities held by each person. As a client in counseling, you have
certain rights and responsibilities that are important for you to understand. There are
also legal limitations to those rights that you should be aware of. I, as your therapist,
have corresponding responsibilities to you. These rights and responsibilities are
described in the following sections.
Therapy has both benefits and risks. Risks may include experiencing uncomfortable
emotional feelings, because the process of therapy often requires discussing the
unpleasant aspects of your life. However, therapy has been shown to have benefits for
individuals who undertake it. Therapy often leads to a significant reduction in feelings of
distress, increased satisfaction in interpersonal relationships, greater personal
awareness and insight, increased skills for managing stress and resolutions to specific
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problems. But, there are no guarantees about what will happen. Therapy requires a
very active effort on your part. In order to be most successful, you will have to work on
things we discuss outside of sessions. We will create a treatment plan that fits your
needs to monitor success.
If you have questions about my procedures, we should discuss them whenever they
arise. If your doubts persist, I will be happy to help you set up a meeting with another
mental health professional for a second opinion.
APPOINTMENTS
Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we
agree on, although some sessions may be more or less frequent as needed. The time
scheduled for your appointment is assigned to you and you alone. If you need to cancel
or reschedule a session, I ask that you provide me with 24 hours of notice. If you miss a
session without canceling, or cancel with less than 24 hours of notice, my policy is to
collect the amount of your payment [unless we both agree that you were unable to
attend due to circumstances beyond your control]. If it is possible, I will try to find
another time to reschedule the appointment. In addition, you are responsible for coming
to your session on time; if you are late, your appointment will still need to end on time. I
will wait up to 15 minutes, and then I will consider the appointment as a “no show”
appointment and we can reschedule or wait until the next scheduled appointment.
PROFESSIONAL FEES
The standard fee for the initial intake is $200.00 and each subsequent session is
$150.00 (45-50 minute session) to $180.00 (50-60 minute session). You are
responsible for paying at the time of your session unless prior arrangements have been
made. Payment must be made by check or cash. If you would like to pay with credit
card you can process it through my Simple Practice telehealth Stripe credit card feature.
Any returned checks are subject to an additional fee of up to $25.00 to cover the bank
fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or
collection agency to secure payment.
In addition to weekly appointments, it is my practice to charge this amount on a prorated
basis (I will break down the hourly cost) for other professional services that you may
require such as report writing, telephone conversations that last longer than 15 minutes,
attendance at meetings or consultations which you have requested, or the time required
to perform any other service which you may request of me. If you anticipate becoming
involved in a court case, I recommend that we discuss this fully before you waive your
right to confidentiality. If your case requires my participation, you will be expected to pay
for the professional time required even if another party compels me to testify.
PROFESSIONAL RECORDS
I am required to keep appropriate records of the mental health services that I provide.
Your records are maintained in a secure location. I keep brief records noting that you
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were in attendance, your reasons for seeking counseling, the goals and progress we set
for treatment, your diagnosis, topics we discussed, your medical, social, and treatment
history, records I receive from other providers, copies of records I send to others, and
your billing records. Except in unusual circumstances that involve danger to yourself,
you have the right to a copy of what I create in your file. Because these are professional
records, they may be misinterpreted and / or upsetting to untrained readers. For this
reason, I recommend that you initially review them with me, or have them forwarded to
another mental health professional to discuss the contents. If I refuse your request for
access to your records, you have a right to have my decision reviewed by another
mental health professional, which I will discuss with you upon your request. You also
have the right to request that a copy of your file be made available to any other health
care provider at your written request. At that time, processing your file may take up to 4
weeks.
CONFIDENTIALITY
I am legally mandated to break confidentiality if you indicate that you plan to harm
yourself, another person, or have harmed or abused another person. My policies about
confidentiality, as well as other information about your privacy rights, are fully described
in a separate document entitled Notice of Privacy Practices. You have been provided
with a copy of that document and we have discussed those issues. Please remember
that you may reopen the conversation at any time during our work together.
CONTACTING ME
I am often not immediately available by telephone. I do not answer my phone when I am
with clients or otherwise unavailable. At these times, you may leave a message on my
confidential voice mail and your call will be returned as soon as possible, but it may take
up to 48 hours for non-urgent matters. If, for any number of unseen reasons, you do not
hear from me or I am unable to reach you, and you feel you cannot wait for a return call
or if you feel unable to keep yourself safe, 1) contact the Whitebird 24-hour Crisis Line
at (541) 687-4000, 2) go to your Local Hospital Emergency Room, or 3) call 911. I will
make every attempt to inform you in advance of planned absences and provide you with
the name and phone number of the mental health professional covering my practice.
OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you will talk with me so
that I can respond to your concerns. Such comments will be taken seriously and
handled with care and respect. You may also request that I refer you to another
counselor and are free to end therapy at any time. You have the right to considerate,
safe and respectful care, without discrimination as to race, ethnicity, color, gender,
sexual orientation, age, religion, or national origin. You have the right to ask questions
about any aspects of therapy and about my specific training and experience. You have
the right to expect that I will not have social or sexual relationships with clients or with
former clients.
©2025 Path of Hope Counseling, LLC
pathofhopeoregon.com
rachel@pathofhopeoregon.com
Physical: 1126 Gateway Loop, Suite 110, Springfield (by appointment)
Mailing: 1863 Pioneer Parkway East #610
Springfield, OR 97477
Phone: (541) 357-9523
Fax: (855) 335-8228