Informed Consent

Informed Consent for Counseling Treatment

Counseling is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client, you have certain rights that are important for you to know about, and there are certain limitations to those rights that you should be aware of. As a counselor, I have corresponding responsibilities to you, too as well.

“Notice of Privacy Practices”


My Responsibilities to You as Your Counselor

I. Confidentiality

With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your counseling. I cannot and will not tell anyone else what you have told me, or even that you are in counseling with me, without your prior written permission. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. 

If you elect to communicate with me by email at some point in our work together, I am willing to respond briefly by return email, but please be aware that email and other electronic media are not completely confidential. I do not use an encrypting program on email at this time.

The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.

  1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

  2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.

  3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.

  4. If you are involved in a court case and a request is made for information about your counseling. If this happens, I will not disclose information without your written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.

Ia. Confidentiality Pertaining to Minors

The purpose of meeting with a counselor is to get help with problems in your life that are bothering you or that are keeping you from being successful in important areas of your life. You may be here because you wanted to talk to a counselor or therapist about these problems. Or, you may be here because your parent, guardian, doctor or teacher had concerns about you. When we meet, we will discuss these problems. I will ask questions, listen to you and suggest a plan for improving these problems. It is important that you feel comfortable talking to me about the issues that are bothering you. Sometimes these issues will include things you don’t want your parents or guardians to know about. For most people, knowing that what they say will be kept private helps them feel more comfortable and have more trust in their counselor. Privacy, also called confidentiality, is an important and necessary part of good counseling.

For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy.

Except for situations such as those mentioned above (see I. Confidentiality), I will not tell your parent or guardian specific things you share with me in our private therapy sessions. This includes activities and behavior that your parent/guardian would not approve of — or would be upset by — but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I feel that you are in such danger, I will communicate this information to your parent or guardian.

School: I will not share any information with your school unless I have your permission and permission from your parent or guardian. Sometimes I may request to speak to someone at your school to find out how things are going for you. Also, it may be helpful in some situations for me to give suggestions to your teacher or counselor at school. If I want to contact your school, or if someone at your school wants to contact me, I will discuss it with you and ask for your written permission. A very unlikely situation might come up in which I do not have your permission but both I and your parent or guardian believe that it is very important for me to be able to share certain information with someone at your school. In this situation, I will use my professional judgment to decide whether to share any information.

Doctors: Sometimes your doctor and I may need to work together; for example, if you need to take medication in addition to seeing a counselor or therapist. I will get your written permission and permission from your parent/guardian in advance to share information with your doctor. The only time I will share information with your doctor even if I don’t have your permission is if you are doing something that puts you at risk for serious and immediate physical/medical harm.

II. Record-keeping

I keep brief records of each session noting the dates we meet, the topics we cover, progress reports from the client’s perspective, interventions and impressions from the counselor/counseling technique(s) and next steps. My records are kept private and not shared with others, in accordance with HIPPA requirements. If record information needs to be shared to further treatment, you must sign a release of information. 

III. Diagnosis

Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you.

IV. Other Rights

You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right counselor for you. You are free to leave therapy at any time, although I recommend finding a way to give me advance notice so that I can help you end treatment well and consolidate gains (please see section below on Ending Counseling). Because I have a limited practice, I do not have 24-hour emergency or “on call” coverage. If you believe you will need a counselor with 24-hour coverage I will be happy to make a referral. If I believe you need a counselor with a specialty I am not versed in or feel adequately prepared to treat, I will make a referral. If you experience a psychiatric emergency, you should call 911 or go to the nearest hospital emergency room rather than waiting for me to call you back. 

V. The Effects of Counseling

The goal of counseling is for you to benefit, and make positive changes towards your wellness goals. The results of counseling can vary. Your willingness to be an active participant in your treatment will contribute to a positive outcome. As we explore aspects of your life, we may touch upon emotionally difficult topics, creating a level of discomfort at times. Please know that this is a part of the process, and that I am committed to helping you work through difficulty. You may be inclined to check-out during stressful times, but hang in there and see where it goes!

VI. Fees

As of 3/1/19: Individual counseling is $85 per 60 minute session. Insurance is not accepted at this time. There is no direct billing with any insurance company, including Medicare. Clients work via a private contract and informed consent with me and are liable for charges of my services without any limits that would otherwise be imposed by Medicare or any other insurance company. You will be asked to pay for each session at the time of the session. Payment can be by check, cash, or credit card. You are responsible for any returned check fees. If you request a session longer than 60 minutes, you will be billed for the amount of time requested (up to 90 minutes max). In home sessions are offered at a rate of $120/hr. Please inquire about availability when scheduling appointment. If you are paying with a debit or credit card, you must sign and submit a payment consent form, which will be kept on file.

VII. Social Media

I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Note from Ta'Shema: Ending Counseling Well

I want to make your counseling experience as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. If you decide to leave therapy, I'd ask that you provide at least two weeks' notice prior to your actual leaving, to allow you the experience of leaving well, with a sense of completion. If I initiate terminating you from our counseling relationship, it will be because I feel that I am not able to be helpful to you any longer. My ethics and license requires that I offer quality service and have my clients’ needs as paramount in my treatment planning. If I no longer feel that I am the best or right practitioner for you, I will offer referrals to other sources of care, but cannot guarantee that they will accept you for therapy or how they will approach your treatment.

Your Responsibilities as a Counseling Client

You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 60 minutes. If you are late, we will end on time and not run over into the next person’s session. If you miss a session without canceling, or cancel with less than 24 hour notice, you will be charged for that session.


If you’re unhappy with what’s happening in counseling, I hope you’ll talk about it with me so that I can respond to your concerns. Please see above section on this page re: Ending Counseling Well.

Client Consent for Counseling

Your signature and consent for treatment with Branch and Vines Counseling Corner signals agreement with and understanding of these policies.

Branch and Vines Counseling Corner


867 Main St.,
Suite 4a1,
Manchester, CT 06040

My Availability


By Appointment




By Appointment


By Appointment




By Appointment


By Appointment