site search by freefind

Sample Informed Consent Form

In some countries, therapists are required by law to have their client read and sign an informed consent form. This form describes the possible risks of therapy, what to do if there are problems, how billing is structured, what happens if therapy is terminated, and all those sorts of questions.

For some clients, the material in the form be a bit surprising, because they were not aware of what can happen in therapy. Obviously, it is very rare to have any sort of problem, but it is prudent to be aware that such a possibility exists. All trauma therapies in particular are like powerful medication - they can do far more than standard therapies, but they can be more challenging than say simple talk therapy or guidance counseling. Your therapist is trained in both the use of a variety of trauma therapies, as well as in what to do if there are any difficulties. And as another advantage to you, your therapist is part of a network of highly trained Peak States clinical specialists who are available to assist if you encounter a problem that your therapist is not familiar with.

Some clients are concerned when they first encounter an 'informed consent' form. In a very real way, this form should be reassuring - it means your therapist is aware of these issues and understands what to do about them. Secondly, these issues exist for all trauma therapies, not just techniques from the Institute for the Study of Peak States. Hence, as an aware consumer, it is a very good sign that your therapist shares this information with you!

The form below was written for the USA. This country requires the most material of any country we know of, so the form is rather lengthy.

To download this form, right click here.

Informed Consent
Revision 2.1 (short)
June 23, 2012
© 2012 By Dr. Grant McFetridge

Therapist’s Name:
Mailing Address:
Office Phone:
Office Email:
Office Hours:

            We’re going to start our work together by going over this informed consent form. Many countries have laws requiring that we do this; but it is a good idea to do anyway, as it will answer some question you wanted answered, or may not have even thought about before. As we cover each item, I’ll have you check it off to show that you and I discussed it to your satisfaction. I’ll keep the original form, and give you a copy for your records.

What are my qualifications and orientation as a therapist?
When you need your car engine fixed, you need to go to a mechanic who knows all about engines – you don’t go to the transmission guy. In the same way, therapists also specialize, and are better at some things than others; and some things they just don’t have the right training for. Thus, I am what is known as a trauma therapist, specializing in healing traumatic memories that you may or may not realize cause you problems. Later, during our discussion of ‘pay for results’, we’ll go over your issue to see if I feel I can help you with your particular problem; but for now, here’s a description of my formal background:

Academic qualifications: ________________________________________________
My formal certification as a therapist or counselor is by (in) _____________________
I am certified by the Institute for the Study of Peak States to use their techniques.
Professional membership(s): ______________________________________________
Therapeutic orientations: _________________________________________________

We’ve discussed what my therapist’s qualifications and therapeutic orientation, and I understand what the therapist is saying.

What issues won’t I work with?
There are certain issues that I will be sending you to see another therapist for. The most important for you to know about is the issue of suicide. If you have suicidal feelings, have attempted to commit suicide, or have made plans to commit suicide, you need to see someone else who specializes in this problem. If this comes up during our work together, I will end our sessions and refer you to another therapist (or other professional) who works with this issue.
            Another problem that might come up involves physical problems like heart conditions. Because therapy might bring up strong emotional and physical reactions, if you have any medical conditions that might put you at risk, we cannot start therapy.

We’ve discussed the areas that my therapist won’t work with, and I understand and agree to this. Additionally, I don’t have any of the suicidal issues that we discussed, nor do I have any physical condition (like heart troubles) that might be triggered by therapy.

Confidentiality and its exceptions
During our sessions, I may be taking written notes, or audio or video recordings. This helps me remember what we accomplished or still need to do; and can help remind you too, because one of the common effects of modern therapy is forgetting what one’s issue used to be (the ‘apex effect’). This material is confidential and is not for other people, even after we finish working together. However, there are some exceptions:

  • if a child is or may be at risk of abuse or neglect, or in need of protection;
  • if I believe that you or another person is at clear risk of imminent harm;
  • for the purpose of complying with a legal order such as a subpoena, or if the disclosure is otherwise required or authorized by law.
  • If you are in couples therapy with me, do not tell me anything you wish kept secret from your partner.
  • I may also disclose information for the purpose of a professional consultation, or for a professional presentation or paper, in which case your identity will remain confidential.
  • I may also be sharing anonymous data (length of time, effectiveness, unusual problems) from our sessions to help improve the quality of the processes we are using.
  • You should be aware that email or cell phones can be monitored by others, so don’t communicate in this way if you wish confidentiality.

We’ve discussed exceptions to confidentiality, and I understand and agree with these terms of therapy.

Benefits and risks of trauma therapy
The trauma-based therapy that we will be doing is intended to heal the specific issue(s) that you and I decide on in our ‘pay for results’ agreement. Trauma therapy may also bring deeper personal insight and awareness; solutions to, or better ways of understanding and coping with problems; improved relationships; significant reductions in feelings of distress; and greater insight into personal goals and values.
            You should know, however, that trauma therapy usually requires that you be willing to examine and discuss difficult topics or times in your life, to experience stronger than usual emotions, and to try out new and different behaviors. The therapy may feel challenging and difficult at times. Uncomfortable feelings and experiences may be addressed (in that you may feel anger, sadness, guilt, grief, loss, frustration, etc.) as well as physical discomforts or pains (nausea, aches, pains). During treatment, you may feel worse before you start to feel better. And I simply may not be able to help you, or, in rare cases, make you feel worse than when we started. However, you ultimately get to decide what we discuss and work with. If you feel uncomfortable or not ready to discuss a particular issue at any point, this is completely okay.
            In your session, we’ll almost certainly be using one or more state-of-the-art therapies such as EMDR, EFT, TAT, TIR, or WHH, depending on your issue and other factors. (They work far better than older trauma techniques.) You should also know that these techniques, although widely used, are still considered experimental and may cause you problems that have not yet been recognized. Also, the techniques you might learn in therapy are for your own use and not to be taught to others, be they partners, family, friends, therapists or clients. This is for their safety, because formal training is needed in case something goes wrong; and also because some of these techniques are trademarked.
            There are other different types of therapy you might want to pursue instead. For example, you might simply need a counselor to help you come to a decision in your life, and not someone to heal the feelings you have around the situation. If you decide to continue, we’ll look at the issue you want to heal, and decide if it is something we can agree on treating, and ways to measure success. And of course, after this discussion, you may realize that not doing anything is the right thing for you at this time.

We’ve discussed therapy’s benefits, risks, and other options available to me, and I understand and choose to continue with trauma therapy.

Benefits and risks of Whole-Hearted Healing™
            In your session, we may use the state-of-the-art therapy Whole-Hearted Healing (WHH) that often involves regression to traumatic prenatal experiences. We may use it because WHH may work when other techniques don’t; it can also heal some problems that the other therapies I know of can’t. On the other hand, as with all the latest powerful trauma therapies, there is a possibility that you may feel emotionally or physically worse after treatment than you did before. This happens because we have made you even more aware of your issue (or triggered a different issue) and been unable to heal it. If this isn’t something you are willing to accept, I recommend that you either visit a non-trauma therapist, just talk to a counselor about your issue, or perhaps do nothing about your issue at this time.
            Fortunately, because I’m certified in WHH, I can call in a specialist from a PeakStates clinic to work with us if we’re not getting results. They employ a more advanced form of the technique than is available to therapists in private practice, greatly increasing the likelihood of success in difficult cases.
            For safety reasons, this technique is for your own use and not to be taught to others, be they partners, family, friends, therapists or clients. This is simply because formal training is needed to know what to do in case unusual problems arise.

We have discussed the risks and benefits of using WHH; I understand that problems may remain after treatment is finished. I am willing to accept the risks and any consequences that may arise.

Benefits and risks of PeakStates processes
There is another kind of therapy, where the focus is on gaining certain ‘peak states’ of consciousness. For example, you can get a continuously quiet mind, or a feeling of peace that is greater than normal.
            So, what are the difficulties or risks with using these processes? First, they involve healing prenatal trauma. If you don’t heal them fully, you may feel badly for a period of time ranging from hours to days, and perhaps longer, until these memories re-submerge and leave your awareness. Secondly, these processes are relatively new and experimental. Long-term effects, if any, have not been studied or researched. This means that there is always the possibility that problems may occur that we have never seen before, and do not know how to deal with. By analogy, this is like a new drug that after a few years turns out to have side effects that only affected some people. If problems happen, I will call in specialists to help, but even they may not be able to solve your problem. Given this, why would you ever want to use such a process? The reason is the same as why you would use a new drug – it can do things that you really want done, and there are no obvious problems (at least so far).
            Obviously, due to safety concerns only a therapist who is trained in these techniques should be using them. If you go ahead with this type of treatment, you must not share the techniques with others, including your spouse or other therapists you know.

We’ve discussed the PeakStates processes benefits and risks. I understand that there may be problems that remain after the treatment is finished. [Circle the choice that applies to you below:]
Yes, I am willing to accept the risks and any consequences that may arise, and use these processes. I agree to not share the techniques to anyone else.
No, I am unwilling to accept the risks or be fully responsible for what happens, and so will not use the processes.

Practical details
If you decide to start therapy, we will start by writing up a ‘pay for results’ agreement for your therapy. Sessions are typically two hours long, but can run overtime; and we’ll agree on a schedule that works for both of us. If you miss three sessions without canceling or with less than 24 hour notice, or cancel therapy before completion (up to five sessions), you may forfeit your deposit (if any). I do not do insurance billing.
            I encourage you to phone if any emergency situations arise from our work between sessions, but other concerns should be addressed in your regular therapy session. My phone number is at the end of this document. When I am unavailable or on vacation, I will provide you with a contact number of someone who can assist you.
            If you have a life-threatening emergency, you must either call the Suicide and Crisis Hotline at _________________, phone emergency services at ___911 in the US and Canada___, or go to the nearest emergency room. I provide only non-emergency therapeutic services by scheduled appointments. If I may need additional or more intensive services, I may refer me to another organization to receive extended services.

We’ve discussed practical details of our work together, especially about emergencies, and I understand and agree to these terms.

Reviews, referrals and ending
In counseling, it is your right at any time to:
  • have a review of your progress and of any of the topics in this form;
  • be provided with a referral to another counselor or health professional;
  • withdraw consent for the collection, use, or disclosure of your personal information, except where precluded by law;
  • end the counseling or therapeutic relationship by so advising the therapist or counselor; (This may forfeit part or all of your deposit, but the amount will be less than or equal to the standard $100/hr rate of the time you’ve already spent in therapy.)
  • access or obtain a copy of the information in your counseling records, subject to legal requirements.
  • Your right of access to or to obtain a copy of your personal information continues after the end of the counseling relationship.
I reserve the right to terminate therapy at any time. This may occur, for example, if I believe that I simply can’t help you. If this happens, there would be no charge to you for our work up to that point and your deposit (if any) would be returned.

We’ve discussed my rights around the termination of therapy, and I understand and agree to these terms.

Concerns or complaints
If you have a concern about any aspect of your counseling, I would prefer that you first address it with me.  If you feel that this is impossible or unsafe, or if your concern is not resolved through our discussion, you should contact the Institute for the Study of Peak States at +1-250-413-3211. If this doesn’t resolve your complaint, you should then contact the local governmental body that regulates therapists in your country.

We’ve discussed how to deal with any complaints or problems I have with my therapist, and I understand and agree to these terms.

“My signature below confirms that I (the client) have read the above, had an opportunity to discuss it with the therapist, had sufficient time to consider it carefully, and had my questions answered to my satisfaction.”

_____________________________          ______________________________
Name of Client                                                       Name of Therapist

_____________________________            ______________________________
Signature of Client                                                Signature of Therapist

_____________________________            ______________________________
Date signed                                                            Signature of Witness (if any)

Revision History
1.0, Sept 1, 2012: First draft of this webpage. The shorter, alternative explanations have been omitted to maximize the detail content.