Counseling with a Provisionally Licensed Professional Clinician Consent Form
Please review and sign below.
Email address *
Client's Name *
This Informed Consent document supplements the regular informed consent you have already been given to sign.
Your assigned therapist is a Licensed Mental Health Counselor (LMHC) or a Licensed Associate Marriage and Family Therapist (LAMFT) or a Licensed Masters Social Worker (LMSW) in the State of New Mexico. Your assigned therapist receives direct supervision under A New Hope Therapy Center Clinical Supervisor, Jessica Cauthorne, LCSW. Your assigned therapist received their Master’s degree in Counseling/Marriage and Family Therapy/Social Work and is receiving supervision to obtain their independent license.

Information gathered in the sessions will be held with the same confidentiality laws of all clients at A New Hope Therapy Center. Session details will be discussed with your therapist’s supervisor for the purpose of feedback and support. Exceptions to this confidentiality occur when there is suspected child/elder abuse, imminent danger to the client or others, a court order, or when a client signs a release of information.

Code of Conduct:
If for any reason you have questions about counseling or are dissatisfied, you have the right to meet with your therapist and/or the Clinical Supervisor, Jessica Cauthorne, LCSW.

Fees and Office Procedures:
As a courtesy we will bill your insurance for your services, however you are responsible for all copays, deductibles and other fees at the time of services. The fee for service without insurance is $90 per session, paid to A New Hope Therapy Center.

Emergency Situations:
You may leave a message at your assigned therapist’s personal number and your call will be returned within 24 business hours. In an emergency situation when an immediate response is necessary, please call 911 or go to the nearest emergency room for attention.

I have read the above and understand the nature of the consent form for services with a provisionally licensed clinician.
Typing your full name indicates consent and agreement: *
Today's Date: *
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