Sally R. Connolly, LMFT John E Turner, LMFT Couples Counseling of Louisville 1169 Eastern Parkway, Suite 2247, Louisville, KY 40217 CouplesCounselingofLouisville.com
CLIENT INFORMATION SHEET AND CONSENT FOR TREATMENT Confidentiality:
Please know that whatever we discuss in therapy is legally held as private and confidential. This means that we will not divulge anything you tell us to anyone except in either of the following conditions: a) You give your permission to talk to another, such as a health-care professional who is providing you treatment. b) You tell me something that we are legally required to reveal to others. For example, therapists are required to report cases of suspected child abuse or elder abuse, or when a client poses a threat to herself/himself or others. If you are seeing one of us for couples therapy, we consider your relationship to be the client. During our sessions, we may see one of you individually for one or more sessions or for part of a session. This will be seen as part of couples’ work. We will not share with your partner what we discuss in therapy; however, we may strongly encourage you to do so. We will not disclose confidential information about your treatment to anyone else unless all persons who participate in the treatment provide permission to release the information or we receive a court order to provide such.
The nature of therapy:
Therapy works best when you are an active partner in the process, so please know that we welcome your feedback or questions about our work at any time. Participating in therapy may result in benefits including but not limited to: • improved interpersonal relationships; • reduced stress and anxiety; • better communication with loved ones; • increased capacity for intimacy; • more balance in life; • deeper self-awareness. Such benefits may require substantial effort on your part, including active participation in the therapeutic process, honesty, and a willingness to change. There is no guarantee that therapy will yield any or all of the benefits listed above.
We urge and encourage you to share with us your observations and evaluation of the therapeutic process. Our goal is to help you solve any problem or concern that brings you in and we want to know if we are providing you with the help that you need. If not, we will talk together about a change in course. Your satisfaction and healing is our goal.
Completion of Therapy:
The length of therapy depends on the specifics of your situation and the progress we achieve. If you think that we are not making progress and you wish to see another therapist. we will offer you referrals to other therapists to. If we don’t think that we are being helpful to you, we are ethically bound to stop treating you and will provide you with referrals to other sources for therapy. We want you to succeed and we may not be the best source for your goals.
Fees and cancellation policy:
Therapy sessions are normally 60 minutes long. John’s fee is $150 for 55 minutes. Sally’s fee is $120 for 55 minutes, payable each session by check, cash, venmo, debit or credit card. Health Savings Accounts also often cover the cost. While we do not accept insurance, we are glad to provide you with an itemized bill in the hopes that your insurance company will reimburse you for the fee. There is no charge for brief phone calls (up to five minutes), but longer phone sessions with you or with any professionals or others you ask us to speak with on your behalf are subject to a charge based on the length of the call.
When we schedule an appointment, that time is reserved entirely for you. Therefore, if you need to cancel an appointment, please let us know at least 24 hours in advance; otherwise, we will have to charge you for the missed session since we will not be able to fill the appointment time on short notice.
Therapist availability:
You can leave messages by voicemail, email or texts at any time and we normally return phone calls within one business day. In a life-threatening emergency, call 911 immediately. The Crisis and Information Center, 589-4313 is another resource.
Please sign below.
By signing, you acknowledge that you have reviewed and fully understand this agreement, that you have had any questions with regard to its terms and conditions answered to your satisfaction, and that you agree to the terms and conditions of this agreement and consent to participate in therapy.
Note: If you have printed out this form and are scanning it and emailing it back, please sign your name on the first line below. If you are filling out this form on an electronic device, please type your name in both the “sign name” and “print name” lines. Doing so will serve as your electronic signature that you understand and agree to the above. Sign Name:_______________________________________________ Print Name:_____________________________________________________ Home phone:_______________________________________ Work phone:_________________________________________________________