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WIT Counseling Services, LLC

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Consent for Treatment


IMPORTANT INFORMATION AND CLIENT CONSENT: Please read and sign at the end stating you have fully read and understand the information below.


You and your therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. As your therapist, I can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. Gifts are not appropriate, nor is any sort of trade of service for service.


WIT Counseling Services, LLC offers counseling services focused on Cognitive Behavioral Therapy and Trauma-Focused Cognitive Behavioral Therapy, amongst individuals and families. I am a skilled and experienced licensed mental health professional and will not provide services outside of my scope of training. Effective psychotherapy is founded on mutual understanding and good rapport between client and therapist. It is my intent to convey the policies and procedures used in our practice, and we will be pleased to discuss any questions or concerns you may have.


Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process, however, moving through the discomfort often becomes the forefront of the therapeutic experiences. While our focus of treatment is to increase the positive benefits of engaging in healthy therapeutic treatment, we cannot guarantee these benefits, of course. Despite our inability to promise specific treatment outcomes, we aim to provide continued focus on your personal goals of treatment. Should you choose not to follow the plan of treatment provided to you by your therapist, services to you may be terminated.


Hours of operation are by appointment and agreed upon by both parties. Individual therapy is $150.00 per session, sliding scale is available. Payments are due at the beginning of each session.

Appointments are typically scheduled on a weekly basis (as determined by client and therapist) and are approximately 45-60 minutes long. More frequent sessions or referrals to outside resources are available if determined appropriate by your therapist. If you must cancel or reschedule your appointment, please call the office at least 24 hours in advance, whenever possible. Failure to meet the 24-hour deadline will result in being charged for the appointment. Being mindful and able to cancel with an appropriate amount of time will free your appointment time for another client.

- Three (3) consecutive missed/failed therapy sessions will warrant unsuccessful termination of therapy services.

- More than 15 minutes late for sessions warrant rescheduling the session the following week, unless the client has established consistency in attendance and promptness, and tardiness has not been an issue; this will be at the discretion of the therapist.

- If you have been mandated to partake in therapeutic services, information shared in reports or testimony in court or in staffings, is typically about the general progress in therapy for the client, and the client’s understanding of issues that led to legal involvement, and how to overcome interpersonal conflict that led to the current areas of concern.

- Sessions can end early with NO refund should the client become belligerent, verbally, or physically threatening; therapist reserves the right to keep themselves safe, as well as others involved in the therapeutic process.


Currently accepting BCBS, CIGNA, & AETNA; If you are using insurance or employee assistance provider to pay for these services, then I will: (1) Expect and accept payment of your copayment amount at the time of service; (2) File your claim with the insurance provider (3) Receive payment from your insurance provider. (4). Expect that you will pay your portion due of copay, co-insurance, deductible, or fee difference at the time of your appointment. If for some reason the insurance has lapsed or the insurance company denies the claim, client is responsible for paying the full fee, at the time of services.

-Acceptable forms of payment: Private pay: Debit/Credit card and Zelle. Please inform ahead of time if you require receipts for insurance reimbursement. Payment information will be held on file via WIT Counseling Services website.


You may encounter a personal emergency which will require prompt attention. In this event, please contact the office regarding the nature and urgency of the circumstances. I will make every attempt to schedule you as soon as possible or to offer other options. Because clients may be scheduled back-to-back, it is not always possible to return a call immediately. However, I will make every effort to respond to your emergency in a timely manner. If your emergency arises after hours, please call 708-808-0644 and your call will be returned during our business hours. If you are experiencing a life- threatening emergency, call 911 or have someone take you to the nearest emergency room for help. When your therapist is Out-of-town, you will be advised.



Your Rights

Seeking and selecting a counselor can be an intimidating process.

As a client, you have the right to:

  • Select a professional counselor who meets your needs.

  • Be treated with consideration and respect for human dignity.

  • Receive specific information about your counselor’s qualifications, including education, experience, national counseling certifications, and state licensure.

  • To receive quality treatment regardless of race, religion, sex, age, gender expression, gender

identity, sexuality, ethnic background, mental and/or physically disabling condition.

  • To be involved in planning your treatment and to be informed about your treatment process.

  • To be involved in your discharge and aftercare planning.

  • To refuse treatment to the extent permitted by law and to be informed of the possible

consequences of your actions.

  • To schedule an appointment with your therapist to review your record and receive any needed

explanation about the contents.

  • Receive a written explanation of services offered, time commitments, fee scales, and billing policies prior to receipt of services.

  • Understand your counselor’s areas of expertise and scope of practice (e.g., career development, adolescents, couples, etc.).

  • Ask questions about confidentiality and its limits as specified in state laws and professional ethical codes.

  • Receive information about emergency procedures (e.g., how to contact your counselor in the event of a crisis).

  • Ask questions about counseling techniques and strategies, including potential risks and benefits.

  • Request additional opinions from other mental health assessment professionals.

  • Understand the implications of diagnosis and the intended use of psychological assessments and reports.

  • Obtain copies of records and reports.

  • Share any concerns or complaints you may have regarding a professional counselor’s conduct with the appropriate professional counseling organization or licensure board.


Your Responsibilities

In order for your counselor to provide the highest quality of services, it is important that clients:

• Adhere to established schedules. If you must miss an appointment, contact your counselor as soon as possible.

• Pay your bill in accordance with the billing agreements.

• Follow agreed-upon goals and strategies established in sessions.

 • Inform your professional counselor of your progress and challenges in meeting your goals.

• Participate fully in each session to help maximize a positive outcome.

 • Inform your counselor if you are receiving mental health services from another professional.

 • Consider appropriate referrals from your counselor.

 • Avoid placing your counselor in ethical dilemmas, such as requesting to become involved in social interactions or to barter for services.


What to Do if You’re Dissatisfied

Remember that a counselor who meets the needs of one person may not meet the needs of another.


If you are dissatisfied with the services of your counselor:

• Express concerns directly to the counselor, if possible.

• Seek the advice of the counselor’s supervisor if the counselor is practicing in a setting where he or she receives direct supervision.

• Terminate the counseling relationship if the situation remains unresolved.

• Contact the appropriate state licensing board, national certification organization, or professional association if you believe the counselor’s conduct to be unethical.



WIT Counseling Services, LLC follows all ethical standards prescribed by state and federal law. We are required by practice guidelines and standards of care to keep records of your counseling. These records are confidential with the exceptions noted below and in the Notice of Privacy Practices provided to you. Discussions between a therapist and a client are confidential. No information will be released without the client’s written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; criminal prosecutions; child custody cases; suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or where, in the therapist’s judgment, it is necessary to warn or disclose; fee disputes between the therapist and the client; a negligence suit brought by the client against the therapist; or the filing of a complaint with the licensing or certifying board. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this matter further. By signing this Information and Consent Form, you are giving consent to the undersigned therapist to share confidential information with all persons mandated by law, and you are also releasing and holding harmless the undersigned therapist from any departure from your right of confidentiality that may result.


If my therapist believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to my therapist to contact any person who is in a position to prevent harm to me or another, including, but not limited to, the person in danger. I also give consent to my therapist to contact the following person(s) in addition to any medical or law enforcement personnel deemed appropriate:


I understand that, in the event of the death or incapacitation of the undersigned therapist, it will be necessary to assign my case to another therapist and for that therapist to have possession of my treatment records. By my signature on this form, I hereby consent to another licensed mental health professional, selected by the undersigned therapist, to take possession of my records and provide me copies at my request, and/or to deliver those records to another therapist of my choosing.


By signing this Client Information and Consent Form as the Client or Guardian of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receive mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time.

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