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Informed Consent for Psychotherapy

Still Waters Counseling Center, LLC

400 Office Park Drive, Suite 230

Mountain Brook, Alabama 35223



Date last modified:  04/15/2023



General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.



The Therapeutic Process

You have taken a very positive step by deciding to seek therapy.  It takes courage and is admirable, please give yourself credit for that.  Your commitment to the therapeutic process is of utmost importance.  The outcome of your treatment depends largely on your willingness to engage in this process.  It is important that you know that it is possible that therapy may, at times, result in considerable discomfort.   It is also possible that it may result in very positive, lasting changes.  While I cannot promise that your behaviors or circumstance will change, I can promise to support you and do my very best to understand you, as well as to help you clarify what it is that you want for yourself and support your work to attain it.




The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

  1. If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.

  2. If a client threatens grave bodily harm or death to another person.

  3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

  4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

  5. Suspected neglect of the parties named in items #3 and # 4.

  6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

  7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.


Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.


If we see each other incidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you.  It would not be appropriate for us to engage in any lengthy discussions outside of the therapy office.

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