Advanced Awareness Counseling LLC
COUNSELING SERVICES
CLIENT CONSENT FORM
COUNSELING is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual goals. Counseling involves sharing sensitive, personal, and private information that may at times be distressing. During the course of counseling, there may be periods of increased anxiety or confusion. The outcome of counseling is often positive; however, the level of satisfaction for any individual is not predictable. Your therapist is available to support you throughout the counseling process.
CONFIDENTIALITY:
All interactions with Advanced Awareness Counseling LLC, including scheduling of or attendance at consultations and appointments, content of your sessions, progress in counseling, and your records are confidential. No record of counseling is contained in any academic, educational, or job placement file. You may request in writing that the counseling staff release specific information about your counseling to persons you designate.
EXCEPTIONS TO CONFIDENTIALITY:
• The counseling staff works as a team. Your therapist may consult with other counseling staff and/or clinical supervisors to provide the best possible care. These consultations are for professional and training purposes.
• If there is evidence of clear and imminent danger of harm to self and/or others, a therapist is legally required to report this information to the authorities responsible for ensuring safety.
• Utah state law requires that staff of Counseling Services who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to county child protection services.
• A court order, issued by a judge, may require the Counseling Services staff to release information contained in records and/or require a therapist to testify in a court hearing.
We appreciate prompt arrival for appointments. Please notify us at 408-375-3311 if you will be late. You may text or call. Six (6) hour notice of cancellation allows us to use the time for others. Cancellations made after this window are subject to a $30.00 cancellation fee.
If this agency cannot meet all of your specific needs you will be provided with referral sources for adjunct or alternative therapies upon request. You are responsible for all payment at the time of service.
I have read and discussed the above information with my therapist. I understand the risks and benefits of counseling, the nature and limits of confidentiality, and what is expected of me as a client of Advanced Awareness Counseling LLC.