Therapy Consent, Policies & Agreement


BENEFITS/OUTCOMES:  The therapeutic process seeks to meet goals established by all persons involved, usually revolving around a specific complaint(s).  Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships.  The therapeutic process may reduce distress, enhance stress management, and increase one’s ability to cope with problems related to work, family, personal, relational, etc.  Participating in therapy can lead to greater understanding of personal and relational goals and values.  This can increase relational harmony and lead to greater happiness.  Progress will be assessed on a regular basis and feedback from clients will be elicited to ensure the most effective therapeutic services are provided.  There can be no guarantees made regarding the ultimate outcome of therapy.

EXPECTATIONS: In order for clients to reach their therapeutic goals, it is essential they complete tasks assigned between sessions.  Therapy is not a quick fix.  It takes time and effort, and therefore, may move slower than your expectations.  During the therapy process, we identify goals, review progress, and modify the treatment plan as needed.

RISKS:  In working to achieve therapeutic benefits, clients must take action to achieve desired results.  Although change is inevitable, it can be uncomfortable at times.  Resolving unpleasant events and making changes in relationship patterns may arouse unexpected emotional reactions.  Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended.  We will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached.

LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for 45 – 50 minutes depending upon the nature of the presenting challenges and insurance authorizations.  It is difficult to initially predict how many sessions will be needed.  We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.  

APPOINTMENTS AND CANCELLATIONS: You are responsible for attending each appointment and agree to adhere to the following policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment within 24 hours of the scheduled appointment time. There is a $35 fee for no shows and late cancellations. If you cancel or reschedule more than once, we may re-evaluate your needs, desires, and motivations for treatment at this time.  

Psychotherapy is a uniquely personal service; therefore, consultations may be briefly interrupted.  I may periodically take time off for vacation, seminars, and/or become ill.  Attempts will be made to give adequate notice of these events.  If I am unable to contact you directly, a colleague may contact you to cancel or reschedule an appointment.  

FEES: The fee for each 45 – 50 minute therapy session is $130 and is due at the time of service.  If using insurance benefits, all copays are also due at the time of service. Any additional patient responsibility is due within a month of invoice. There will be a $15 late fee added for each month past the due date. Acceptable forms of payment are: exact-amount cash, check (insufficient-funds checks will be returned upon full payment of the original amount plus $50 for any returned check), or credit/debit card (3% convenience fee).  In the event that a scheduled appointment time is missed or cancelled less than 24 hours, please refer to the “Appointments and Cancellations” policy above.  

The clinician reserves the right to terminate the counseling relationship if more than two sessions are missed without proper notification. 

TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case.  In order to protect your confidentiality, I strongly suggest not being involved in the court.  If I get called into court by you or your attorney, you will be charged a fee of $250 to include travel time, court time, preparing documents, etc.  

COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records, the cost is $2 per page.  Payment for your medical records will be due prior or upon receipt and can be picked up at the office.  Please allow at least 2 weeks to prepare medical records.    

PHONE CONTACTS AND EMERGENCIES:  If you need to contact the clinician for any reason please call 732-479-1519, leave a voicemail, and a return call will be made within 24 hours or as soon as the clinician is available.  In case of an emergency, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255.  If either you or someone else is in danger of being harmed, dial 911.  


Anything said in therapy is confidential and may not be revealed to a third party without written authorization, except for the following limitations:

  • Child Abuse: Child abuse and/or neglect, which include but are not limited to domestic violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc. If you reveal information about child abuse or child neglect, I am required by law to report this to the appropriate authority.
  • Vulnerable Adult Abuse: Vulnerable adult abuse or neglect. If information is revealed about vulnerable adult or elder abuse, I am required by law to report this to the appropriate authority.
  • Self-Harm: Threats, plans or attempts to harm oneself. I am permitted to take steps to protect the client’s safety, which may include disclosure of confidential information.
  • Harm to Others: Threats regarding harm to another person. If you threaten bodily harm or death to another person, I am required by law to report this to the appropriate authority.
  • Court Orders & Legal Issued Subpoenas: If I receive a subpoena for your records, I will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information. I will contact you twice by phone. If I cannot get in touch with you by phone, I will send you written correspondence.  If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in the order.  Despite any attempts to contact you and keep your records confidential, I am required to comply with a court order.  
  • Court Ordered Therapy: If therapy is court ordered, the court may request records or documentation of participation in services. I will discuss the information and/or documentation with you in session prior to sending it to the court.
  • Written Request: Clients must sign a release of information form before any information may be sent to a third party. A summary of visits may be given in lieu of actual “psychotherapy/process notes”, except if the third party is part of medical.  If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released.  
  • Fee Disputes: In the case of a credit card dispute, I reserve the right to provide the necessary documentation (i.e. your signature on the “Therapy Consent & Agreement” that covers the cancellation policy to your bank or credit card company should a dispute of a charge occur. If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted.
  • Couples Counseling & “No Secret” Policy: When working with couples, all laws of confidentiality exist. I request that neither partner attempt to triangulate me into keeping a “secret” that is detrimental to couple’s therapy goal. If one partner requests that I keep a “secret” in confidence, I may choose to end the therapeutic relationship and give referrals for other therapists as our work and your goals then become counter-productive.  
  • Dual Relationships & Public: Our relationship is strictly professional. In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (ie: social, business, or friendship). If we run into each other in a public setting, I will not acknowledge you as this would jeopardize confidentiality.  If you were to acknowledge me, your confidentiality could be at risk.   
  • Social Media: No friend requests on our personal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current or former clients. If you choose to comment on our professional social media pages or posts, you do so at your own risk and may breach confidentiality. I cannot be held liable if someone identifies you as a client.  Posts and information on social media are meant to be educational and should not replace therapy.  Please do not contact me through any social media site or platform.  They are not confidential, nor are they monitored, and may become part of medical record. 
  • Electronic Communication: If you need to contact me outside of our sessions, please do so via phone.
  • Clients often use text or email as a convenient way to communicate in their personal lives.  However, texting introduces unique challenges into the therapist–client relationship.  Texting is not a substitute for sessions.  Texting is not confidential.  Phones can be lost or stolen.  DO NOT communicate sensitive information over text.  The identity of the person texting is unknown as someone else may have possession of the client’s phone.
  • Do not use e-mail for emergencies.  In the case of an emergency call 911, your local emergency hotline or go to the nearest emergency room.  Additionally, e-mail is not a substitute for sessions.  If you need to be seen, please call to book an appointment.  E-mail is not confidential.  Do not communicate sensitive medical or mental health information via email.  Furthermore, if you send email from a work computer, your employer has the legal right to read it.  E-mail is a part of your medical record.  
  • Sessions Outside the Office: From time to time, clients like to meet in an alternate location (i.e. their home, in public, or somewhere more conducive for them). We may be able to accommodate this request, however, this can put your confidentiality at risk.



  1. I have read and understand the information contained in the Therapy Agreement, Policies and Consent. I have discussed any questions that I have regarding this information with Poonam Patel, MS, LPC.  My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent.  I authorize PDP Associates LLC to provide counseling services that are considered necessary and advisable.
  1. I authorize the release of treatment and diagnosis information necessary to process bills for services to my insurance company, and request payment of benefits to PDP Associates LLC. I acknowledge that I am financially responsible for payment whether or not covered by insurance.  I understand, in the event that fees are not covered by insurance, PDP Associates LLC may utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney.
  1. Consent to Treatment of Minor Child(ren) (if applicable): I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Poonam Patel, MS, LPC to provide treatment to my minor child(ren). If I have unilateral decision-making capacity to obtain counseling services for my minor, I will provide the appropriate court documentation to PDP Associates LLC prior to or at the initial session.  Otherwise, I will have the other legal parent/guardian sign this consent for treatment prior to the initial session. 



If you are seeing one of our team members who is provisionally licensed to practice in their professional field (LAC or LSW), please read this information.  Provisionally licensed clinicians are highly skilled and already have years of experience before they are hired at Phoenix Wellness Center.


Information gathered in clinical sessions will be held with the same confidentiality laws of all clients at Phoenix Wellness Center. Clinical details will be discussed with your clinician’s supervisor for the purpose of training. Exceptions to confidentiality are the same as the practice policies when there is suspected child/elder abuse, imminent danger to the client or others, a court order, or when a client signs a release of information.  

What does it mean to be Provisionally Licensed?
All provisionally licensed clinicians have completed 2+ years of graduate education in a counseling or social work curriculum and up to 800 hours of practicum experience before becoming provisionally licensed.  Clinicians complete 3,000-3,500 client hours before receiving full licensure.  The full timeline for transitioning from provisional to full-licensure takes about 2-3 years of rigorous training.

If you have any questions about this information, please speak with your counselor or you may email the Clinical Director at [email protected]