Consent
Form
Dear
Client:
Before
we start our work together, you should know that you have certain
rights and responsibilities. In addition, as your counselor I also have
rights and responsibilities.
- You
have the right to a free, no obligation, one time consultation with Mr.
Lynn T. Austrheim, to ask questions and to discuss your challenges and
goals.
- Your
counselor is a Licensed Clinical Social Worker and is not a
physician/medical doctor, and does not practice medicine. If medical
treatment or medicine is required your counselor will recommend that
you see a physician. Your counselor takes no responsibility for
services provided by other professionals.
- Confidentiality
is your right. Within legal limits, clinical information revealed by
you to your counselor, will be kept strictly confidential. Even the
fact that you are a client is confidential.
- An
exception to confidentiality is that your counselor is required by law
to report any incidences of child or elder abuse or neglect to the
proper authorities. In addition, the threat of bodily harm or death to
another person will reported to the proper authorities and, if known,
to the person threatened.
- The
Counseling Advantage and Mr. Lynn T. Austrheim do not warrant or imply
the confidentiality of any information conducted by electronic means.
If you require special security measures, discuss your requirements
with your counselor.
- You
have the right to choose that certain therapeutic techniques not be
used.
- No
audio or video recordings will be made of your sessions unless you
grant permission in writing.
- You
have the right to end counseling at any time, without any moral, legal,
or financial obligation, except for financial debt for past counseling.
If you have more than two unexcused absences from your telephone or
face-to-face consultation, it will be assumed that you have terminated
your counseling.
- If
your counselor cannot be reached and you need help, it is your
responsibility to seek another resource or to use the services of a
hospital emergency facility.
- Your counselor reserves the right to end counseling at
any time without any explanation.
By
clicking on the I AGREE button above, I confirm that I have
read, or have had someone read to me, all of the above text, and that I
fully understand all of the features, rights, and obligations I have as
a client. I also state, as a client of counseling, that I willingly and
freely agree to participate in the counseling program as described in
this document.
Mr. Lynn T. Austrheim, M.S.W., L.C.S.W.
CounselingAdvantage@gmail.com
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