I understand that therapy often involves discussing difficult aspects of life and I may experience feelings like sadness, guilt, anger, frustration, loneliness and helplessness in the course of our work.

It is also my understanding that the benefits of psychotherapy include but are not limited to: increased self awareness, improved interpersonal relationships, a vitalized sense of self, discovery of meaning and purpose in life, solutions to problems, greater ability to express thoughts and emotions, and reduction in feelings of distress.

I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my therapist my condition may not improve, and in some cases may even feel worse. I will discuss my ongoing experiences in therapy and ask about alternative courses of action when I wish.

As a necessary element of Therapist self care, confidential information may be discussed with a Supervisor, and peer supervision including this therapist’s partner in practice. Details will be presented without identifying information such as my name.

I understand that the consequences of not engaging in psychotherapy are varied and cannot be defined in a general way.

I understand that I have the following rights with respect to psychotherapy:

  • I understand that my therapist may use a wide variety of therapeutic techniques, including psychodynamic, somatic, humanistic and transpersonal methods, emotionally focused therapy, EMDR, Interpersonal Neurobiology and will suggest exercises based in this varied methodology. My therapist will explain these to me as is reasonable in the process of our work together.
  • I have the right to withhold or withdraw consent at any time to all or part of this, while respecting the proper conduct of therapy, without affecting my right to future care or treatment.


The information disclosed by me during the course of my therapy is confidential. However, there are exceptions to confidentiality, including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards a victim; legal subpoena.

  • I understand that I have the right to access my file and copies of records on request, subject to reasonable notice.
  • I have a right to a receipt for services on request, subject to reasonable notice.
  • If I have any questions or feel uncomfortable with the process of therapy, I understand that I have the right to bring them up in conversation with my therapist.

I understand that I have the following responsibilities with respect to Psychotherapy:

  • I recognize that therapy is a mutual process in which there is a shared responsibility for decision-making and action toward healing, growth and realization of potential. My responsibility includes the recognition of my own agency and capacity for choice and the necessity that I be engaged in the creation, development and enactment of all therapeutic processes.
  • I agree to be responsible for the fee of ______ per session. I understand further that I will be given reasonable notice before any anticipated change of fees. If my circumstances change I can discuss a change of fee. I agree to pay for services when delivered unless other arrangements are agreed upon.
  • I understand that there is a 24-hour cancellation notice requirement. I agree to be responsible for payment for any planned session I do not attend, if I have not given at least 24 hours notice. I understand that this does not apply to emergency situations, in which case I agree to give as much notice as possible.


I can communicate with my therapist via email but understand that confidentiality may be compromised due to the technology used.

If my therapist responds via email in depth, I will be charged for her time accordingly.


  •  I will notify my therapist of my prescription medications and any changes in their usage.
  • I agree to share information regarding my mental and physical health as assessed by previous practitioners, including any disagreements I may have with their perspectives.

If my needs are beyond the scope of the therapist’s expertise, I will accept a referral to another practitioner.


I have discussed this information with my therapist and my questions have been answered to my satisfaction. I hereby consent to psychotherapy treatment.


Signature of client: _____________________________________________________

Date: _______________________________________________________________


Welcome to my practice.
I sincerely commit to working with you to the best of my ability so that your psychotherapy experience will be deeply rewarding.

Please print this form, sign and bring to your first meeting.

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