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ENCOURAGEMENT Christian Counseling & Coaching Beverly J. Miller, MHC, NCC, BC PCC, Executive Director 4610 Bluebird Road, Canandaigua, New York 14424 5853960590 voice 5853939477 faxes www.EncouragementCCC.com
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How to Fill Out Informed Consent to Psychotherapy:

01
Start by clearly identifying the participant: Begin the informed consent form by stating the participant's name, contact information, and any relevant demographics such as age and gender.
02
Provide a clear purpose: Explain the purpose of psychotherapy and what the participant can expect from the process. Specify that psychotherapy involves discussing personal and sensitive topics, and that it aims to promote emotional well-being and personal growth.
03
Explain the confidentiality policy: Emphasize the importance of maintaining confidentiality throughout the therapy process. Clearly outline the boundaries and limitations of confidentiality, such as situations where the therapist may be legally obligated to disclose information, or situations where the participant's safety might be at risk.
04
Describe the therapist's qualifications and approach: Provide information about the therapist's credentials, experience, and the therapeutic approach they utilize. This helps the participant gain a better understanding of what to expect from the therapy sessions.
05
Discuss potential risks and benefits: Inform the participant about potential risks and benefits associated with psychotherapy. Mention that while therapy can be beneficial, it may also bring up uncomfortable emotions or memories temporarily.
06
Seek consent for treatment: Clearly state that the participant has the right to refuse or discontinue therapy at any point. Ensure the participant understands that they have control over their own treatment and can actively engage in the decision-making process in collaboration with the therapist.
07
Provide information about fees, scheduling, and cancellations: Include details about the therapist's fees, availability, and the cancellation policy. This helps the participant have a clear understanding of logistical aspects and expectations surrounding appointments.
08
Include contact information: Include the therapist's contact information, emergency contact numbers, and crisis intervention resources in case of urgent situations or after-hours support.

Who Needs Informed Consent to Psychotherapy?

01
Individuals seeking psychotherapy: Informed consent is necessary for individuals who are voluntarily seeking therapeutic services to address psychological, emotional, or behavioral concerns.
02
Minors and their legal guardians: If the participant is under 18 years of age, their legal guardian should provide informed consent on their behalf. The guardian should be fully aware of the nature of the treatment and its potential risks and benefits.
03
Participants with limited decision-making capacity: In cases where individuals have limited decision-making capacity, their legal representative should give consent for them. This may include individuals with cognitive impairments, psychiatric conditions, or other circumstances that prevent them from comprehending the informed consent process adequately.
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Informed consent to psychotherapy is a process where a client gives permission to a therapist to provide treatment, after being informed of the potential risks, benefits, and alternatives.
Both the therapist and the client are required to participate in the process of informed consent to psychotherapy.
Informed consent to psychotherapy is typically filled out by the therapist and the client together, discussing and agreeing upon the terms of treatment.
The purpose of informed consent to psychotherapy is to ensure that the client understands the treatment being provided, including its risks and benefits, and agrees to participate in it.
Information such as the therapist's credentials, treatment plan, confidentiality policies, and fees should be reported on the informed consent to psychotherapy form.
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