Informed Consent for Services
Client Name: ______________________________________
Date: ___________________________
Date of Birth: ____________
I hereby give my consent to enter into counseling services with Mary Dainty, LPC-S d.b.a. Texas LPC
Supervision & Counseling. I understand by engaging in counseling with Mary Dainty, LPC-S, I agree to the
following:
Counselor
I have been made aware of my Counselor’s qualifications and have chosen to engage in
counseling with her. My license is issued by the Texas State Board of Examiners of Professional
Counselors (License # 18640).
Nature of Counseling
I understand I must be honest and willing to share personal information about myself and be an
active participant if counseling is to be effective. I understand that counseling may at times be
difficult and/or unpleasant, depending on the issues that are discussed.
I understand that my relationship with my Counselor is strictly professional and that my
Counselor will not acknowledge me in public unless initiated by me (client). My Counselor will
not engage in an extended conversation with me in a public place or discuss any issues related
to our Counseling sessions.
Assessment & Evaluation
I understand my first session will be an information gathering session in order to determine
issues that need to be addressed and recommendations for how to address such issues. I
understand my evaluation may result in a diagnosis. I understand my Counselor may, at times,
utilize testing instruments (i.e. Beck Depression Inventory, SASSI, DES II, etc.) in order to best
determine my Counseling needs.
Course of Counseling & Treatment Planning
I understand the number, frequency, and duration of my Counseling sessions will be determined
based upon my specific needs. I understand that I will collaborate with my Counselor to develop
a treatment plan and agree to work toward my treatment goals.
Family Involvement
I understand I may request family involvement in my Counseling and agree to discuss this with
my Counselor prior to scheduling any such session(s).
1
Confidentiality & Records
I have been given a list of the confidentiality/privacy policies of Mary Dainty, LPC-S. I understand
my Counselor will not discuss or disclose confidential information about my Counseling without
written consent, with exception in those situations identified in the HIPPA disclosure. If you
have any questions regarding confidentiality, you should discuss them with your Counselor
during your treatment.
Termination of Services
I understand I may choose to terminate Counseling services at any time. I am aware that my
Counselor may recommend termination of counseling services and will provide referrals if she
feels the issues are outside of her treatment scope.
Payment of Services
Payment is expected at the time services are rendered and you will be provided a receipt for
services via Square. All major credit cards and cash are accepted. I am not a contracted provider
for in-network insurance benefits. You may request that your insurance provide out-of-network
benefits and file your own paperwork. You Counselor will not be responsible for any filing of
benefits.
If you have a Health Savings Account (HAS), Flexible Spending Arrangement (FSA), Medical
Savings Account (MSA), or Healthy Reimbursement Arrangement (HRA) please check with your
plan administrator for details on this.
I acknowledge and agree to pay Mary Dainty, LPC-S d.b.a. Texas LPC Supervision & Counseling
for services:
Individual Counseling (50 mins): $80 (the price will go up $10 for every 10 extra minutes needed)
Family Counseling/Couples (50 mins) $100
Phone Consultation lasting longer than 10 minutes but less than 45 minutes: $30
In the event your records are required by law for court or testimony purposes, payment will be expected
from you, regardless of whose attorney subpoenas my involvement. For legal proceedings that require
my response, you will be billed $300 per hour. In addition to this fee you will be billed the following for
administrative purposes (and any other fees not mentioned but necessary for my involvement):
Court Testimony Preparation: $50 per hour / Court Record Preparation $80 per hour / Mileage related
to Court Testimony and Subpoenas $ .75 per mile / Copy of Record(s) $ .25 per page / CounselingAssessment Report $40
2
Crisis Situations
In the event of a crisis, every effort will be made to return your call and schedule if necessary.
However, please understand that your Counselor may be in sessions and unable to return your
call until a later or the next business day. Should you need immediate assistance or experience a
crisis after hours or on a weekend, please call your Primary Care Physician, 911, National Suicide
and Prevention Hotline at 1-800-273-TALK (8255) or go your local Emergency Department for
evaluation. In Tarrant County there are two Hospitals that have Inpatient Psychiatric Units- John
Peter Smith (JPS) and Huguley Memorial. Free standing Inpatient Psychiatric Hospitals in Tarrant
County are Mesa Springs, Millwood, and Sundance Center.
Duty to Warn/Duty to Protect
In the event my Counselor believes I (or minor child a client) is at risk of harming myself or
someone else, I give my permission for my Counselor to contact anyone listed below. In addition
to these people law enforcement and/or medical personnel may be contacted.
Name of friend/family member: ________________________
Phone #: _______________________
Name of friend/family member: ________________________
Phone #: _______________________
Scheduling & Cancellations
I agree to attend all of my scheduled sessions and to call, text or email at least 24 hours ahead of
time if I will not be able to attend my session for any reason. I understand I will be required to
pay a “no show” fee of $80 if I cancel less than 24 hours before my scheduled appointment or
fail to show for my scheduled appointment. No further appointments will be scheduled until the
balance is paid in full. Failure to pay any outstanding fees will result in collection actions.
By signing this Client Informed Consent for Services Form, I acknowledge that I have read and
understand all the terms, conditions, & information contained herein. I have been provided sufficient
opportunity to ask questions and seek clarification of anything contained in the agreement that is
unclear to me.
_____________________________________
________________________________
Client Signature/Legal Guardian Signature
Date
_____________________________________
________________________________
Counselor Signature
Date
3
Permission for Professional Services for a Minor:
I have the legal authority to seek and grant permission for professional services for a minor
child. If applicable you may be asked to provide proof of such authority.
Name of child: ______________________________
Date of Birth: _____________________
Name of child: ______________________________
Date of Birth: _____________________
Name of child: ______________________________
Date of Birth: _____________________
Client Family Member Signatures: All family members who are involved in Counseling need to sign
below indicating an understanding of these policies and procedures. If you have any questions, please
discuss them with your Counselor before you sign.
Print name
Signature
Relationship to Client
Date of Birth
4