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THIS SAMPLE AGREEMENT, SERVICES AND CONSENT/DISCLOSURE
FORM MAY BE FREELY COPIED, MODIFIED AND USED IN YOUR
COUNSELING SERVICES. COUNSELSOURCE IS NOT RESPONSIBLE
FOR THE QUALITY OR OUTCOME OF ANY COUNSELING, NOR DO WE
ACCEPT RESPONSIBILITY FOR ANY SERVICES OR OUTCOMES NOT
DIRECTLY UNDER OUR CONTROL. ANY AGENCY OR COUNSELOR
USING OUR FORMS IS RESPONSIBLE FOR THE QUALIFICATIONS,
CERTIFICATIONS, AND OUTCOMES OF ANY SERVICES THEY
PROVIDE.


A. AGREEMENT FOR COUNSELING SERVICES

THIS DOCUMENT SHALL GOVERN ALL PROFESSIONAL RELATIONSHIPS BETWEEN THE
PARTIES. [YOUR CHURCH, AGENCY, OR MINISTRY NAME] (HEREIN REFERRED TO AS THE
AGENCY) SHALL PROVIDE SUPERVISED STAFF AND SUITABLE FACILITIES FOR
COUNSELING. THE CLIENT (SIGNATURE AT END OF THIS DOCUMENT) HAS REVIEWED A
COPY OF CLIENT RIGHTS AND RESPONSIBILITIES. IT IS AGREED THAT ALL DISPUTES
BETWEEN CLIENT AND ASSIGNED COUNSELOR, OR CLIENT AND AGENCY, SHALL BE
SUBMITTED TO MEDIATION. ANY DISPUTES OR MODIFICATIONS TO THIS AGREEMENT
SHALL BE: 1) FIRST NEGOTIATED BETWEEN CLIENT AND ASSIGNED COUNSELOR; IN THE
EVENT A SETTLEMENT CANNOT BE REACHED, 2) CLIENT SHALL SUBMIT THE DISPUTE TO
THE DIRECTOR OF COUNSELING AT THIS AGENCY FOR MEDIATION; IF A MUTUALLY
SATISFYING RESOLUTION CANNOT BE EFFECTED; 3) CLIENT SHALL BE ADVISED OF
OPTIONS REGARDING REFERRAL OR DISCONTINUANCE OF COUNSELING.


IF YOU ARE A CHURCH OR CHRISTIAN AGENCY YOU MAY WISH TO INCLUDE A STATEMENT
ABOUT YOUR THEOLOGICAL POSITION OR TRADITION (Baptist, Pentecostal, Presbyterian, etc.) AND DESCRIBE YOUR
INTENT TO UTILIZE THE BIBLE, PRAYER, AND/OR OTHER CHRISTIAN PRACTICES IN THE COUNSELING PROCESS.


B. ASSIGNED COUNSELOR

THE ASSIGNED COUNSELOR (SIGNATURE AT END OF THIS DOCUMENT) IS:

(check all that apply)


____ A PROFESSIONAL, LICENSED AS ___________________

     BY THE STATE OF __________


____ PRELICENSED, UNDER SUPERVISION

     IN THE STATE OF __________


____ A GRADUATE STUDENT FROM [university or program]

     SERVING INTERNSHIP OR PRACTICUM


____ A PASTORAL COUNSELOR CERTIFIED AS _____________

     BY [certifying organization]


     (all counselors at this agency are supervised)
      [use this phrase if applicable]


YOUR COUNSELOR WILL DISCUSS YOUR CASE WITH

  [supervisor's name and highest academic degree and
   licensure]


C. COUNSELING POLICY REGARDING DURATION

COUNSELING WILL BE LIMITED TO TEN SESSIONS AT WHICH TIME COUNSELING
PROGRESS WILL BE EVALUATED. FOLLOWING EVALUATION: 1) COUNSELING MAY BE
TERMINATED, IF IN THE OPINION OF COUNSELOR, CLIENT, AND AGENCY, MUTUALLY
AGREED GOALS HAVE BEEN REACHED; 2) CLIENT AND COUNSELOR AGREE THAT
SATISFACTORY PROGRESS HAS BEEN MADE AND CLIENT CAN SAFELY CONTINUE WITHOUT
FURTHER AGENCY SUPPORT; 3) COUNSELOR AND CLIENT AGREE THAT AN IMPASSE HAS
BEEN REACHED; OR 4) IT IS DEEMED IN THE CLIENT'S BEST INTEREST TO BE
REFERRED TO ANOTHER COUNSELOR OR AGENCY. COUNSELING MAY BE EXTENDED BEYOND
THE INITIAL TEN SESSIONS IF: 1) COUNSELOR, CLIENT, AND SUPERVISOR AGREE
THIS IS IN THE CLIENT'S BEST INTEREST; 2) CLIENT IS SATISFACTORILY
PROGRESSING TOWARD AGREED GOALS AND WOULD SIGNIFICANTLY BENEFIT BY MORE
SESSIONS; 3) CLIENT IS WILLING TO SIGN THE CONTINUANCE AGREEMENT. OPTIONS
WILL BE DISCUSSED BETWEEN CLIENT AND COUNSELOR TO DETERMINE CLIENT'S BEST
INTEREST AND CHOICES.


D. FEES AND PAYMENT POLICY

   SERVICES AT THIS AGENCY ARE (use phrasing applicable to
   your ministry or agency)

   1. OFFERED AT THE RATE OF [your rate] PER FIFTY-MINUTE
      SESSION WITH A COUNSELOR OR TECHNICIAN.

   2. GENERALLY OFFERED WITHOUT CHARGE.

   3. OFFERED ON A SLIDING FEE SCALE.
      (attach your fee schedule)

   4. OFFERED WITHOUT CHARGE BUT CLIENTS MAY ELECT TO
      DONATE FUNDS TO HELP EXTEND SERVICES TO OTHERS.

   5. SOME SERVICES (for example: tests, outside
      consultation, or adjunct services from another
      agency) MAY REQUIRE A FEE. SUCH SERVICES WILL BE
      DISCUSSED BETWEEN CLIENT AND COUNSELOR AND AGREED
      TO IN WRITING BEFORE ANY FEES ARE CHARGED. CLIENT
      IS RESPONSIBLE FOR ALL AGREED FEES.

   6. WE ACCEPT INSURANCE FROM THE FOLLOWING PROVIDERS
      [list those you accept]. CLIENT IS RESPONSIBLE FOR
      CO-PAYMENT OF [your rate] PER SESSION AND OTHER
      AGREED TO FEES [if any].


E. CANCELLATION POLICY

WE AGREE TO AND ASK THAT CLIENTS MAINTAIN RESPONSIBLE RELATIONS REGARDING
APPOINTMENT SCHEDULES. CLIENTS ARE RESPONSIBLE TO NOTIFY THIS AGENCY
TWENTY-FOUR HOURS IN ADVANCE FOR ANY CANCELLATION OF SCHEDULED
APPOINTMENTS. IN THE EVENT THE CLIENT ARRIVES LATE FOR A SCHEDULED
APPOINTMENT; 1) TIME FOR THAT SESSION WILL NOT BE EXTENDED; 2) TWO
CANCELLATIONS WITHOUT TWENTY-FOUR HOUR ADVANCE NOTICE MAY RESULT IN
TERMINATION OF COUNSELING AT AGENCY DISCRETION.


F. CONFIDENTIALITY POLICY

ALL THERAPEUTIC COMMUNICATIONS, RECORDS, AND CONTACTS WITH COUNSELORS,
SUPERVISORS, AND SUPPORT STAFF SHALL BE HELD IN STRICT CONFIDENCE.
INFORMATION MAY BE RELEASED, IN ACCORDANCE WITH STATE LAW, WHEN: 1) THE
CLIENT SIGNS A WRITTEN RELEASE OF INFORMATION INDICATING INFORMED CONSENT
TO SUCH RELEASE; 2) THE CLIENT EXPRESSES INTENT TO HARM SELF OR OTHERS AND,
IN THE OPINION OF THE COUNSELOR, THE THREAT IS ASSESSED AS REASONABLY
SERIOUS; 3) THERE IS EVIDENCE OR, IN THE OPINION OF THE COUNSELOR,
REASONABLE SUSPICION OF SEXUAL, PHYSICAL, OR OTHER ABUSE AGAINST A MINOR OR
ELDERLY PERSON; OR 4) A COURT ORDERS RELEASE OR DISCLOSURE OF CONFIDENTIAL
INFORMATION. IT IS THE POLICY OF THIS AGENCY TO ASSERT EITHER 1) PRIVILEGED
COMMUNICATION; OR 2) IN THE EVENT OF NUMBER "4", THE RIGHT TO CONSULT WITH
THE CLIENT, IF AT ALL POSSIBLE, BARRING AN EMERGENCY, BEFORE A MANDATED
DISCLOSURE. THOUGH THIS AGENCY CANNOT GUARANTEE TO CONSULT WITH THE CLIENT
IN THE EVENT OF MANDATED DISCLOSURES, WE WILL ENDEAVOR TO APPRAISE CLIENTS
OF SUCH DISCLOSURES.


ANY CONCERNS REGARDING THIS POLICY OF CONFIDENTIALITY MUST BE RAISED BY THE
CLIENT PRIOR TO SIGNING THIS AGREEMENT TO RESOLVE THEM IN THE CLIENT'S BEST
INTEREST, OR CLIENT WILL BE DEEMED IN AGREEMENT.


G. WORKING AGREEMENT

CLIENT AGREES TO MAKE GOOD-FAITH EFFORT AT PERSONAL GROWTH AND ENGAGE IN
THE COUNSELING PROCESS AS AN IMPORTANT PRIORITY AT THIS TIME OF HIS/HER
LIFE. CLIENT UNDERSTANDS THAT COUNSELING IS A COLLABORATIVE ENDEAVOR
REQUIRING THE CLIENT'S WILLINGNESS TO FULLY COOPERATE IN ACHIEVING MUTUALLY
AGREED GOALS. CLIENT GAINS ARE, TO A LARGE DEGREE, DEPENDENT UPON HIS/HER
COMMITMENT TO THE GROWTH PROCESS. LACK OF PROGRESS, BEHAVIORS THAT INDICATE
NON-COOPERATION (such as: missing appointments, refusing to carry out
mutually agreed therapy programs, three or more tardy arrivals for
appointments) MAY RESULT IN TERMINATION OF THIS AGREEMENT. 


H. EMERGENCIES

CRISES MAY ARISE BETWEEN SESSIONS WHICH CAUSE UNUSUAL OR SEVERE DISTRESS.
IN SUCH CASES CLIENT IS REFERRED TO EMERGENCY TELEPHONE NUMBERS. WITHOUT
PRIOR WRITTEN AGREEMENT, COUNSELORS AT THIS AGENCY ARE NOT PERMITTED TO
RECEIVE EMERGENCY CALLS.


I. TAPING AND SUPERVISION

ALL COUNSELORS AT THIS AGENCY ARE UNDER SUPERVISION AND WILL DISCUSS YOUR
CASE WITH THEIR DESIGNATED SUPERVISOR. FOR YOUR USE, OR FOR THE PURPOSES OF
PROVIDING MORE EFFECTIVE COUNSELING AND SUPERVISION, YOU CAN GIVE WRITTEN
PERMISSION TO AUDIO OR VIDEO TAPE YOUR COUNSELING SESSIONS. CLIENTS SHOULD
DISCUSS THIS WITH THEIR COUNSELOR BEFORE SIGNING A TAPING AGREEMENT.



   _____________________________________ ______________
   CLIENT'S SIGNATURE                     DATE



   _____________________________________ ______________
   CLIENT'S SIGNATURE                     DATE



   _____________________________________ ______________
   COUNSELOR'S SIGNATURE                  DATE


   _____________________________________ ______________
   SUPERVISOR'S SIGNATURE                 DATE



 Copyright 1997 COUNSELSOURCE