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This is to certify that I give my consent to Hansink and Associates to provide counseling to myself and/or my children. I understand that counseling may include talking about problems, learning relaxation techniques, neurofeedback therapy, communication skills, assertiveness skills, anger management skills, stress management skills, as well as other relational skills. I understand that therapy is a process, not an event. I also understand that in the process of the therapy relationship, painful emotional feelings can emerge and the working through of these feelings is essential to the healing process and to my personal growth. The therapist will be available to help in this working through process. I understand that gaining maximum benefit from the therapy requires regular attendance and a commitment to the process. It also requires that I be honest, both intellectually and emotionally. The therapeutic relationship is a privileged one. All communications with the counselor are confidential and not to be shared outside the therapy relationship. There are some exceptions to confidentiality. These must be noted. There are four basic exceptions to confidentiality. The first exists when the client becomes a danger to self or others. The therapist has a duty to protect the client from harm and that may require breaking the client’s confidentiality. The second occurs when the client threatens to harm someone and the therapist believes that there is imminent danger to the threatened party. In this case, the therapist has a mandate to warn the victim and to inform the police. Third, if, in the course of treatment, it comes to the therapist’s attention that child abuse or elder abuse has occurred, the therapist has a mandate to report this to the appropriate authorities. Child abuse includes physical abuse, sexual abuse, emotional abuse, or neglect of a child or minor. The fourth exception of breaking confidentiality occurs when the therapist is mandated by a court of law. I understand these limits to confidentiality. When a whole family or a couple is the client, it is very important that there be an understanding and an agreement about the flow of information. A unique case also exists when a minor is the client. It is important for the parents as well as the minor to know what information will and will not be shared. Should you cancel your appointment within 24 hours of your scheduled time, you agree to be responsible for payment of the fee. By signing below I am acknowledging that I understand and agree to the above policies. *

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HIPAA - ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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