Counseling Informed Consent Template

This Counseling Informed Consent (“Agreement”) is entered into on [Date], by and between:

Counselor: [Full Name, Credentials, License Number, Practice Address]
Client: [Full Legal Name, Address, Contact Information]

Together referred to as the “Parties.”

1. Purpose of Counseling

Counseling is a collaborative process intended to support personal growth, emotional well-being, and problem-solving. The Counselor will provide services using appropriate therapeutic methods and professional standards.

2. Confidentiality

• All client information will be kept confidential except as required by law (e.g., threats of harm, child abuse, court orders).

• Records will be securely stored and only shared with written client consent.

3. Risks and Benefits

• Counseling may involve discussing sensitive issues that can trigger emotional discomfort.

• Benefits may include improved coping skills, self-awareness, and healthier relationships.

• No guarantees of specific outcomes can be made.

4. Session Details and Fees

• Session length: [e.g., 50 minutes]

• Fee per session: $[Amount]

• Payment is due [at time of service / monthly]

• Missed sessions or cancellations with less than [X hours] notice may incur fees.

5. Client Rights

Clients have the right to:

• Ask questions about treatment methods.

• Decline specific interventions.

• Request referral to another professional.

• End counseling at any time, subject to financial obligations for services already rendered.

6. Counselor Responsibilities

The Counselor agrees to:

• Provide services in accordance with professional ethical standards.

• Maintain licensure and professional competency.

• Respect the client’s dignity, autonomy, and values.

7. Emergencies

Clients experiencing crises outside of session times should call [Emergency Hotline Number] or 911. The Counselor may provide referrals to additional resources as appropriate.

8. Acknowledgment

By signing below, the Client confirms that they understand the counseling process, confidentiality terms, risks, benefits, and financial obligations, and consent to participate.

Signatures

Counselor: ____________________________ Date: _________
Name/Title: _________________________________________

Client: ____________________________ Date: _________
Name: ______________________________________________