‘From Under the Rug’ Consent for Mental Health Therapy (Florida)
This form, also called ‘Informed Consent’, is your consent to receive personal therapeutic treatment. This form must be signed in order to continue with services. Without your consent, I cannot treat you. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by providing your signature at the end of this document.
The Therapeutic Counseling Process:
First, all information shared with me as your Mental Health Therapist is considered confidential and will not be disclosed unless authorized by you explicitly OR it results in the directly/indirectly expressed intent of self-harm/neglect or to another with an execution plan. The goals of my consulting are designed to empower you to take directional power over your situation(s) and keep our lines of communication open for future therapeutic processes. This is achieved by understanding and defining the primary stressors in your life, pinpointing those stressors that are within your control, and implementing the necessary changes to take control of those stressors. I will also help you to cope with and accept the factors that are not within your control.
The outcome of your therapeutic sessions depends largely on your willingness to engage as openly and honestly in this process, which may, at times, result in some discomfort. I cannot promise that your circumstance will change. However, I can promise to support you as well as to help you clarify what it is that you want for yourself.
What to Expect from Our Relationship:
I am pre-licensed under the clinical supervision of Dr. Jennifer Guerriero, LCSW (Florida License #SW11785) and trained to practice clinical social work. If needed, she may be reached at
. I am not able to give you good advice from other professional viewpoints such as law or finance. If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. It is in your best interest to hire a different professional for any evaluations or testimony you may require. This stance is based on two reasons:
1. My statements will be seen as biased in your favor because we have a personal therapeutic relationship.
2. The testimony might affect our personal consultation relationship, and I must put our relationship first.
Consultations and Referrals:
Occasionally, I may need to consult with other professionals in their areas of expertise in order to provide the best counseling for you. Information about you may be shared in this context without using your name. Without breaking your confidentiality, I am able to gain perspective about your particular situation.
If you could benefit from a service that I cannot provide, I will do my best to help you to get it. You have a right to ask me about such other therapeutic practices, their risks, and their benefits. Based on what I learn about you, I may recommend a myriad of solutions best suited for your personal progression.
If for some reason my therapeutic approach is not showing signs of positive progression, I might suggest you see another therapist. As a responsible person and ethical therapist, I cannot continue to treat you if my treatment is not working for you. If you wish for another professional's opinion at any time, or wish to talk with another mental health therapist, I will help you find a qualified person and will provide him/her with the information needed, only if authorized by you.
It is the policy of this office to record all consulting sessions in an audio/.WAV/.mp3/.mp4 format. However, there may be times where a time in our session may be noted for further review. The rationale for recording sessions are as follows:
1. Audio recording the sessions provides both the client and consultant with an added value of not having many note-taking interruptions during the consultation session. This helps free both parties to truly be focused on the conversation.
2. Recordings are destroyed after notes have been interpreted and added to your secured client file.
Agreement/Consent to Therapeutic Treatment:
I, the client (or his/her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the therapeutic process I have questions about any of the subjects in this document, I can discuss them. I understand that I have the right to withdraw my consent to therapeutic treatment at any time, for any reason. However, I will make every effort to discuss my concerns about my progress before ending therapy sessions. I understand that no specific promises have been made to me by this consultant about the results of personal consultation, the effectiveness of the procedures used by this Mental Health Therapist, or the number of sessions necessary for consultations to be effective. I have read, or have had read to me, the full spectrum of this document.
I agree to act according to all information covered in this document and I consent to mental health counseling. My printed/typed name will act also in lieu of my signature.
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