Libratum Counseling, LLC                                                142 W. Market St., 2nd Floor        

610.616.5890                                                                West Chester, PA 19382

Information and Informed Consent for Treatment

Thank you for choosing Libratum Counseling, LLC as your provider.    Please read the following information in order to understand our professional relationship.

INFORMED CONSENT FOR TREATMENT

This is to certify my consent for psychotherapy for myself and/or my minor children. This is a voluntary choice and I am free to discontinue treatment at any time.

I understand that psychotherapy is a cooperative effort between myself and my therapist, and there is no assurance that I will feel better, although treatment is expected to be helpful.  I understand that sessions are 45/60 minutes in length and that specific results regarding therapeutic goals are not guaranteed.  If you are late, we will end on time and not run over into the next person's session.

I understand that during the course of my therapy, some material may be discussed which may be upsetting.  Such discussions may be an essential component of the treatment and are only undertaken to support the process of resolving problems.

You normally will be the one who decides therapy will end, with three exceptions. If we have contracted for a specific short-term piece of work, we will finish therapy at the end of that contract. If your therapist is not, in their judgment, able to help you because of the kind of problem you have or because their training and skills are in their judgment not appropriate, your therapist will inform you of this fact and refer you to another therapist who may meet your needs. If you do violence to, threaten, verbally or physically, or harass your therapist, the office, any of the staff or their families, your therapist reserves the right to terminate you unilaterally and immediately from treatment. If your therapist terminates you from therapy, we will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy.

CONFIDENTIALITY STATEMENT

All information shared in this treatment is confidential except in circumstances governed by law.  These situations include: (1) intent to harm self and/or others; (2) child and/or elder abuse; (3) court order to disclose information; (4) if you direct to tell someone else and sign a “Release of Information” form.  If you are utilizing insurance, your insurance company may require information regarding your treatment on an ongoing basis in order to authorize services.  Please note that I have no control over information once it is released to a third party.  By signing this form you are acknowledging that you understand and agree to these limitations of confidentiality.

EMERGENCIES/COVERAGE

If you are experiencing an emergency when your therapist is out of town, or outside of regular office hours please call Valley Creek Crisis Hotline at (610) 918-2100 and/or (610) 280-3270 or 911. If you believe that you cannot keep yourself or someone else safe, please call 911, or go to the nearest hospital emergency room for assistance. Outpatient private practice is not designed to provide intense treatment to ensure a client’s day-to-day functioning as many inpatient and/or intensive outpatient programs may be designed to do.  We cannot assume responsibility for a client’s daily functioning.  It is the responsibility of the client to discuss expectations of after-hours care upon intake in order to ensure an appropriate referral.  If there is a fear that a client may harm him/herself or another, call 911.  

In the event your therapist is away from the office due to vacation(s) or to attend professional meetings, and if they are not taking and responding to phone messages during those times we will have someone cover their practice. Your therapist will tell you well in advance of any anticipated lengthy absences, and give you the name and phone number of the therapist who will be covering their practice during the absence. We are available for brief between- session phone calls during normal business hours.

My signature below indicates that I have read and understand this information sheet and informed consent.  

_____________________________________                              ____________________

Client (14 yrs. or older)                                          Date

_____________________________________                              ____________________

Provider                                                             Date

_____________________________________                              ____________________

Parent or Guardian                                                             Date