Farrer Counseling

Informed Consent Form

Welcome. I’m Emily Farrer, I am a Licensed Mental Health Counselor, I received my Masters of
Mental Health Counseling from Bridgewater State University and am licensed by the state of
Massachusetts.

Therapy has both benefits and risks. Risks may include experiencing uncomfortable feelings,
such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the
process of therapy often requires discussing the unpleasant aspects of life. However, therapy
has been shown to have benefits for individuals who undertake it. Therapy often leads to a
significant reduction in feelings of distress, increased satisfaction in interpersonal relationships,
greater personal awareness and insight, increased skills for managing stress and resolutions to
specific problems. To get the most out of counseling, it is recommended that you use what you
learn in session when you leave the office. Therapy does not stop when you leave the office.
The more you use what you learn in session, the more therapy will be helpful to you.

The information you share with me during therapy sessions is considered confidential
information and is protected by state law. As a licensed mental health counselor, I cannot
reveal to third parties whether or not you are a past or current client of mine and cannot
disclose any of the information you discuss during our sessions without first obtaining your
written consent to do so. In the following instances, however, I may be mandated or allowed to
share information without your written consent:
• If during your therapy, you are deemed to pose a threat of harm to someone else or to
yourself, I am allowed to collaborate with the police or a hospital to take necessary
measures to prevent harm from happening.
• If you talk about events that lead me to believe that a child under the age of 18 or an
elderly or disabled person is at risk for emotional, physical or sexual abuse, neglect, or
exploitation, I am required by state law to make a report to Texas Family and Protective
Services with or without your consent.
• If you are not yet 18 years of age, your parents or legal guardians may have access to
your records and may authorize release of information to other parties on your behalf.
• If you disclose sexual misconduct by a previous therapist. I am required to make a
report to the licensing board governing the license of the therapist.
• If a judge in a court of law orders me to release information or if I need to respond to
a lawfully issued subpoena.
• If I need to cooperate with legal actions against a mental health professional by a
licensing board.
• If you submit an out-of-network health insurance claim and the insurance provider
needs information to authorize the therapy or the billing.
Additional Rights:

 The client may ask questions on what to expect during and end result of the therapy.
 The client may decline to proceed the therapy as to the techniques which may be
conducted by the therapist.
 The client may cease to continue therapy anytime, without any impediment and may
return to therapy anytime.
 The therapist has the right to dismiss the client from the course of therapy.
 The client has the right to review his or her records from the therapist.
 Referrals: If client has a particular concern needing a specialized treatment approach
(e.g. a couples therapy, EMDR therapy, family therapy, sex therapy, alcohol or drug
problems specialist, etc.), therapist has the right to refer the client to another specialist
in the field.
 Consultation: Anonymous supervision will be carried out with therapist's supervisor.
 The client can raise any concerns and to speak with the therapist immediately of any
concerns provided that the therapist is likewise available to discuss matters with the
client.

I am often not immediately available by telephone. I do not answer my phone when I am with
clients or otherwise unavailable. I do not have 24-hour emergency or “on call” coverage. At
these times, you may leave a message on my confidential voice mail and your call will be
returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any
number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel
you cannot wait for a return call or if you feel unable to keep yourself safe go to your Local
Hospital Emergency Room, or call 911 and ask to speak to the mental health worker on call. I
will make every attempt to inform you in advance of planned absences, and provide you with
the name and phone number of the mental health professional covering my practice.

You are responsible for paying any co-payments and deductibles that are not covered by your
insurance company. Co-pays will be collected at the time of service. If you do not have
insurance coverage, we will make an effort to notify you before your appointment. You will be
directed to the Patient Services Department for assistance with coverage. We accept several
insurance plans. For information on whether we accept a particular plan, please ask the front
desk reception. We also have a sliding scale fee plan if you are unable to secure insurance
before your visit
CONSENT TO PSYCHOTHERAPY
Your signature below indicates that you have read this Agreement and the Notice of Privacy
Practices and agree to their terms.
_________________________________________
Signature of Patient or Personal Representative
_________________________________________
Printed Name of Patient or Personal Representative
_________________________________________
Date _____________________________________
Description of Personal Representative’s Authority: _____________________________
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