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Couselling Consent Form

The document is a consent form for counseling services provided by the Nagaoka Health Care Center. It outlines the counseling system including fees, cancellation policies, duration of services, and potential referral to other providers. It also describes the confidentiality policy, exceptions for legal requirements or risk of harm, and potential use of de-identified case information for professional development. Clients must sign to acknowledge understanding and consent to the policies if deciding to receive counseling.

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BLAST REHAN
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33 views1 page

Couselling Consent Form

The document is a consent form for counseling services provided by the Nagaoka Health Care Center. It outlines the counseling system including fees, cancellation policies, duration of services, and potential referral to other providers. It also describes the confidentiality policy, exceptions for legal requirements or risk of harm, and potential use of de-identified case information for professional development. Clients must sign to acknowledge understanding and consent to the policies if deciding to receive counseling.

Uploaded by

BLAST REHAN
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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COUNSELING CONSENT FORM

Nagaoka Health Care Center

Nagaoka Health Care Center aims to provide peace and satisfaction to those who have mental health challenges,
their families, and those involved in our community. As one of our mental health care, we provide counseling
services. Please read this important information about our services and policies carefully. If you decide to
participate the counseling services, please sign it.

[Counseling System]
1. We offer face-to-face counseling only. We don't offer counseling via phones or emails.
2. Counseling fees are as follows:
50 minutes session: 10,000 yen (plus tax)
25 minutes session: 5,000 yen (plus tax)
* Counseling is not covered by insurance.
* Please pay the fee each time at the reception.
3. There is the following charge if you do not cancel counseling appointments by the day before.
* When you cancel by the scheduled time on the day: 50% of the counseling fee
* No-show: 100% of the counseling fee.
4. If you do not reschedule or make contact with the counselor within 3 months, it will be assumed that you are
no longer interested in continuing counseling. If you would like to return to counseling, you need to make a
newly appointment.
5. If you are receiving treatment or counseling from other medical facilities or services, your counselor may
contact your doctor or person in charge with your consent.
6. Please follow the counseling policies throughout the course of counseling. If your medical condition becomes
unstable or you violate the policies, the counselor may terminate the service.
7. Please note that your counselor may refer you to another health care provider who can better meet your needs.
8. Please note that your counselor may change for any reason.

[Confidentiality]
1. Information discussed during your therapy session and all documentation is kept private and confidential.
Counselors don't disclose your information without your consent. Some very important exceptions to this rule
are:
(1) If there is a legal responsibility for the therapist to release information contained in records.
(2) If we believe that you are threatening imminent physical injury to yourself or another person.
2. Counselors may present your case at professional conferences or study groups in order to enhance their skills
and knowledge. Your personal information will be de-identified to protect your confidentiality.

If you have any concerns regarding this document, feel free to ask your counselor. If you read the above carefully
and decide to receive counseling, please sign below.

I have read the above material and understand its provisions. I understand that the results of counseling vary
from person to person and that achieving a positive outcome depends upon my efforts as well as those of my
counselor.

Date

Client

Parent, Guardian

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