Client - Counselor Consent Form

Client-Counselor Consent Form

In order for Connie Clark, Ph.D. to counsel with you as a client online or by telephone, you must agree to the following: By filling out and returning this Client-Counselor Consent Form, you indicate that you understand and agree to the terms and conditions stated below.

You agree that you are at least 18 years old.
You understand that I am a NCCA Licensed Clinical Christian Counselor, a NCCA Licensed Pastoral Counselor and a NAFC Certified Cognitive-Behavioral Therapist.
You agree that you have read the separate section on Confidentiality, below, and you agree with the terms set out in that section.
You agree to supply your true full name, address, and phone number on the Client Questionnaire. You agree that all of the information you have provided to me in the Client Questionnaire is accurate, and that if any of this information is inaccurate, this may be a major limitation on my ability to help you.
You understand that I cannot guarantee a positive counseling outcome, even though I am hopeful that our work together will be of help to you. In addition, you understand that online counseling is a new counseling procedure and its research and effectiveness is just beginning. Therefore, you understand that online counseling with me is an experimental counseling procedure at this time.
You agree that online and telephone counseling is not equally safe and effective for all individuals. Thus, I reserve the right to choose whether or not to work with you online or by telephone. I will work with you only if I feel that you are a suitable client. If, during our work together, I discover that you are not a client that can benefit from online or telephone counseling, I will discuss this with you and suggest that you seek face-to-face counseling help through other mental health professionals in your local area such as a psychiatrist, psychologist, social worker or another Christian counselor. In addition, I may suggest that you seek help with your pastor or a local pastor in your area.
You understand that online and telephone counseling and face-to-face psychotherapy are not the same. Therefore, I cannot make any formal diagnoses for online or telephone counseling nor carry out traditional psychotherapy online. In addition, if at any point in our work together I believe that it would be in your best interests to see a counselor face-to-face for, I will explain this to you and ask that you locate a counselor in your local area to work with.
You agree and understand that the effectiveness of online and telephone counseling depends on the investment of time and energy you are willing to make. Generally speaking, the more you invest in it, the more you will get out of it.
You agree that I cannot be held responsible for providing services to you in the event of a crisis or emergency situation. While I will do my best to continue to provide services as appropriate if a crisis or emergency develops during our work together, you may need to find a local therapist if such a situation arises.
You understand that I cannot be held responsible for unforeseen problems that may occur in my online and telephone services due to my computer malfunctioning, and/or loss of electricity or Internet connection. My office phone number is posted on this website; if you don't hear from me when you expect to, please don't hesitate to call me at this number. However, bear in mind that if there is an electrical outage, the phone lines may also not be working, temporarily.
Confidentiality In General: You understand and agree that as a counselor, I protect the confidentiality of the communications and contacts with all of my clients, including online and telephone clients. I will only release information about our work to others with your written permission except in the following situations:
1. If I learn while we are working together that a child, elderly person, or disabled person is being abused, I am required to notify appropriate protective services.
2. I am required to do so by a court order or legal subpoena.
3. If you tell me while we are working together that you are considering committing suicide, committing serious self-injurious behavior or considering violence towards another person, I am required to notify the appropriate authorities.
4. Confidentiality Online: You understand that when receiving counseling through email, online or telephone, it is almost impossible to guarantee 100% confidentiality protection. I will do everything possible to protect against any intrusions on my end, and I ask that you do the same. It is my belief that the single biggest threat to confidentiality is a result of sending messages where the confidentiality of your own messages sent to me or mine sent to you is not secure. If you send/receive emails from your work computer, your supervisor or superior may be able to or entitled to view these emails. And unless you have your own password-protected email account at home, family members and others with access to your email account may be able to breach your confidentiality. So please be sure that you're not sending/receiving emails either from your workplace or from an unsecured email account at home. When using your home computer, please make sure that you are the only person with access to your personal email account. In terms of confidentiality problems with telephone sessions, please understand that if you choose to use a cordless or cell phone during a phone session with me, someone with a scanner could possibly hear you talk. Finally, there is always the remote possibility that a hacker will breach the confidentiality of our email transmissions. To my knowledge, this has never happened to a counselor who is working online, e.g. confidentiality being breached by hackers, but there is always a first time. To summarize, there are risks to your confidentiality online, as there are in an office setting as well. However, I believe these risks to be extremely small assuming common sense is used and appropriate precautions are taken to protect emails sent and received.
The goal of our online or telephone counseling is to help you. Therefore, if either of us feels, at any time, that working together is not helpful enough to you; either of us is free to terminate our relationship at any time.

There are no other explicit or implicit commitments in our relationship.