Disclaimer

Last updated January 16, 2025

Authentic Living Therapy

Informed Consent for Psychotherapy

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. 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 filling in the checkbox at the end of this document.

The Therapeutic Process You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

In Case of an Emergency

In the event of an emergency, it is important to prioritize immediate safety and seek appropriate help. I am not available to provide emergency or crisis intervention services. If you are experiencing a mental health crisis or an urgent situation, please contact 911, go to the nearest emergency room, or call a local crisis hotline for immediate assistance. For ongoing support outside of our sessions, you can also reach out to resources such as the Suicide & Crisis Lifeline at 988. Your safety and well-being are of utmost importance, and these resources are best equipped to provide timely assistance in emergencies.

Location of Therapy

When participating in telehealth therapy sessions, clients must be physically located in the state of Minnesota, as required by licensing regulations. As a licensed therapist in Minnesota, I am legally permitted to provide therapy services only to clients within the state during sessions. It is the client’s responsibility to ensure they are in Minnesota at the time of their telehealth appointment. If you expect to be outside of Minnesota during a scheduled session, please inform me in advance so we can discuss how this may affect your therapy. Compliance with this requirement helps maintain the integrity and legality of the therapeutic process.

Confidentiality The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Release of Records

Your privacy and confidentiality are of utmost importance in therapy. However, there may be instances where the release of your medical records is necessary or requested. Medical records will only be released with your written consent, specifying the information to be disclosed, the purpose of the disclosure, and the recipient. Exceptions to this include situations where release is required by law, such as a court order, mandatory reporting of abuse or neglect, or if there is an immediate risk of harm to yourself or others. If you wish to request or authorize the release of your records, please discuss this with me, and I will provide the appropriate release forms to ensure your rights and privacy are protected.

Payment Policy

The fee for each therapy session must be paid in full before the start of the next scheduled appointment. To streamline this process, a valid credit card must be kept on file. If payment is not received prior to the next session, any future appointments may be canceled until the balance is paid in full. This policy ensures fairness and consistency while allowing us to maintain high-quality services for all clients. Please contact us with any questions or concerns about payment arrangements.

Cancellation Policy

The cancellation policy is designed to ensure that appointment times are used effectively and to respect the time set aside for each client. If you need to cancel or reschedule your session, we ask that you provide at least 24 hours' notice. Cancellations made with less than 24 hours’ notice, or missed appointments, will incur a $75 fee. This policy helps cover the time reserved specifically for you, as last-minute cancellations or no-shows make it challenging to offer the slot to another client in need.

Social Media Policy

To maintain professional boundaries and protect your privacy, I do not engage with clients on social media platforms. This includes following, “friending,” liking, commenting, or direct messaging on platforms such as Facebook, Instagram, X, LinkedIn, or others. Engaging with clients on social media may compromise confidentiality and blur the boundaries of our therapeutic relationship.

I encourage you to communicate with me through the client portal for any questions or concerns. Additionally, if you come across my professional social media accounts or content, you are welcome to view them but are discouraged from interacting with them to protect your confidentiality.

Electronic Communication

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages (when available). Communication will take place through the client portal. While I may try to return portal messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. In case of an emergency, call 911.

Minors

Authentic Living Therapists do not treat minors. All clients must be 18 years of age or older.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive months, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.