Informed Consent for Psychotherapy

MICHELLE WAKELEY LICSW LLC 

Doing Business As (DBA) AWAKEN MENTAL WELLNESS

726 E. Park Ave. #185

Fairmont, WV 26554

(304) 534-9321

info@awakenmentalwellness.com

EFFECTIVE DATE: September 23, 2026

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 Informed Consent for Psychotherapy should be reviewed together with the Awaken Mental Wellness Practice Policies, which outline administrative procedures, fees, scheduling, communication expectations, and other practice-related information.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The contents of our sessions and your clinical record will be kept confidential except as permitted or required by law. Clients may request in writing that records or portions of records be released to specifically identified individuals or entities. Such disclosures require appropriate written authorization unless otherwise permitted or required by law. 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.

8. Information related to treatment may also be disclosed for purposes of treatment, payment, or healthcare operations as permitted under HIPAA regulations.

Electronic Communication

Email, text messages, voicemail, and the client portal are intended primarily for scheduling and administrative communication. While reasonable safeguards are used, electronic communication carries inherent privacy risks. If you need to contact between sessions, it is preferred that you do so through the Client Portal as it is most secure. If you choose to leave a message on my voice mail or email, I will attempt to reply as soon as possible. This is a solo private practice and I am unable to provide 24 crisis support. If a true emergency situation arises, please call 911 or any local emergency room. For other crisis support: You can contact the National Suicide Prevention Lifeline at 988 or 1-800-273-TALK(8255). The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones. You may contact Help304 at www.help304.com (chat), or 1-877-HELP304 (text/call). Help304's professional crisis counselors are available 24/7 and trained to listen and help you find the way forward with stress-management strategies as well as community resources and referrals. You can contact HELP4WV at www.help4wv.com (chat), or 1-844-435-7498 (text/call). Help4WV is a 24/7 call, chat, and text line that provides immediate help for any West Virginian struggling with an addiction or mental health issue. These contacts are also listed under Resources at www.awakenmentalwellness.com

Consultation

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information may be shared for consultation purposes while taking reasonable steps to protect your privacy, such as limiting identifying information whenever possible.

Dual Relationships

Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual relationships are discouraged as they may present increased risk for the client, including potential for conflict of interest and breach of confidentiality. If it comes to the attention of this therapist that a Dual Relationship exists there may need to be a discussion regarding how to navigate the potential ethical dilemma or referral to another provider if necessary to avoid an ethical conflict.

Public Encounters

If we see each other accidentally outside of the therapy environment, 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, but I believe it is appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Social Media

In accordance with the NASW Code of Ethics, due to the importance of your confidentiality and the importance of minimizing dual relationships, 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.

Consent for Telehealth Visits

By signing this document, I acknowledge:

• I understand that my health care provider wishes me to engage in telehealth visits.

• I understand that The Telehealth by SimplePractice is the primary videoconferencing platform used by my provider. I also understand that, when clinically or operationally appropriate, other HIPAA-compliant telehealth platforms for which the practice maintains a signed Business Associate Agreement (BAA) may be used, including but not limited to Google Meet, Sessions by Psychology Today, Doxy.me, and Doximity. Regardless of the platform used, reasonable administrative, technical, and physical safeguards will be implemented to protect the privacy and security of my protected health information in accordance with applicable law.

• I understand how the video conferencing technology used to conduct my appointments works, and I understand that I will not be in the same physical location as my provider during telehealth sessions.

• I understand that telehealth has potential benefits including easier access to care and the convenience of meeting from a location of my choosing provided I am physically located in a state where my therapist is legally authorized to practice.

• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider will attempt to reconnect via established method of contact if connection is interrupted, and will attempt a predetermined alternative contact method if necessary. I understand that my health care provider or I can discontinue the telehealth visit if it is felt that the videoconferencing connections are not adequate for the situation.

• I understand that neither the client nor the therapist may audio or video record telehealth sessions without the prior written consent of the other party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

• I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

• I understand that if I am having suicidal or homicidal thoughts, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth services are not appropriate and a higher level of care is required.

• I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency. I agree to provide an accurate physical location at the beginning of each telehealth session in case emergency services need to be dispatched.

• I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

Consent to use The Telehealth by SimplePractice Service

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. By signing this document, I acknowledge:

• Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

• Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

• The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

• I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

• To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

Appointments 

The standard meeting time for psychotherapy is 50 minutes. Requests to change the standard 50-minute session must be discussed with the therapist in advance. Extended sessions are subject to availability and may result in additional charges.

48 Hour Cancellation Policy

Please remember to cancel or reschedule 48 HOURS IN ADVANCE. Cancellations and re-scheduled sessions may be subject to a full charge on the day of service unless changes have been agreed upon at least 48 hours in advance. This is necessary because a time commitment is made to you and is held exclusively for you. Unless other agreements have been made, if you are late for a session by 15 minutes you will have forfeited your allotted time. Late cancellations and no-shows will be charged the full session fee. Your therapist will address frequent cancellations (three consecutive appointments are missed or canceled, or three non-consecutive appointments are missed or canceled within a six month period) with you as this may negatively impact planned therapeutic work.

Therapist Cancellation

I will make every effort to keep our scheduled appointments. If I am aware of a need to cancel or reschedule well in advance I will discuss this with you in session. If I become aware of a need to cancel between the time of your last appointment and 48 hours from your next appointment I will message you through the Client Portal. If I need to cancel within 24 hours of your next appointment due to illness or emergency I will contact you directly via text or phone call. In the event I am unable to communicate a pre-authorized and appointed representative will reach out to you on my behalf.

I will make deliberate efforts toward maintaining professional standards for self-care and competence by planning time off. The practice will be closed for most major holidays (New Year’s Day, MLK Day, Good Friday, Memorial Day, Juneteenth, Independence Day, Labor Day, Thanksgiving, Black Friday, Christmas, and New Year’s Eve). I will also plan at least 4 weeks of time off per year, typically about a week per season, including around Christmas. In addition, I will occasionally be away for trainings, consultation, and continuing education events. Prior to planned time away I will inform you of the planned absence, attempt to reschedule if possible, and review resources you may contact while I am unavailable.

Payment of Services

Each client will enter into a Payment Agreement prior to the start of services. A credit card is required to remain on file and will be billed within 48 hours following the time of service via AutoPay through Simple Practice, unless other arrangements are made. The Payment Agreement will be reviewed bi-annually, and is subject to change.

A Good Faith Estimate will be provided to any client identified as Self-Pay or using Out-of-Network benefits in accordance with the No Surprises Act.

Payment Agreements and Good Faith Estimates cover regular and expected services. Additional services, including request for documents, consultation, and court-related activities may incur additional charges.

This therapist reserves the right to change fees. Clients will receive notice via Simple Practice and awakenmentalwellness.com at least 60 days in advance of any fee changes. 

Court-Related Activities 

The client understands requesting this therapist to participate in any court-related activities may jeopardize the client's confidentiality. To secure this therapist's attendance in court there will be a retainer fee the client must pay in advance. The retainer reserves up to three consecutive business days of professional availability. I agree to pay in advance all other court-related costs (including communicating with attorneys, preparing documents, providing testimony, etc.) at a rate of $150 per hour, regardless of Payment Agreement for individual therapy. I understand that court-related costs are non-negotiable and separate from typical professional therapy services. I understand these costs are necessary due to the disruption that court activities may cause for others receiving care.

Limits of State-Bound Licensure

Although interstate licensure is likely in the near future, currently licensure is state-bound, meaning you must be physically present in the state in which your therapist holds licensure at the time of session. There is no exception. If you are physically outside of the state of West Virginia for any reason or by any proximity (including if you are vacationing in another state or just barely over the state line) you will not be able to meet with your therapist, your session will be forfeited, and you may be held financially responsible for the cost of the session.

Termination

You may terminate treatment at any time, and it is suggested that you do this openly to allow for closure and referrals, if needed. I may terminate treatment after appropriate discussion with you if I determine that the psychotherapy is not being effectively used or if you are in default on payment. In accordance with my professional ethics, I will not allow you to accrue a bill and acquire debt as a result of care, and thus, future services may be canceled if payment for a previous service has not been rendered. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If I determine termination is necessary, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

For legal and ethical reasons, the client will have self-discharged/terminated services as soon as three consecutive appointments are missed or canceled, three non-consecutive appointments are missed or canceled within a six month period, or no appointments are scheduled for three weeks. If the client wishes to resume services, there may or may not be a spot available. If services are resumed there will need to be a new Payment Agreement signed.

Professional Disclosure Statement

Therapist’s name: Michelle Wakeley

Position: Therapist for Michelle Wakeley LICSW dba Awaken Mental Wellness

Business Address: 726 E. Park Ave. #185, Fairmont, WV 26554

Business Phone: (304) 534-9321

National Provider Identification Number: 1629465786

Professional License Number: DP00944505

License Level: LICSW

Original License Date: 11/2014

Professional Education: Masters of Social Work, West Virginia University, Graduated 2009; Bachelors of Science in Psychology, Fairmont State University, Graduated 2005

Areas of Competence: Individual assessment, diagnosis, and treatment of mental and emotional disorders, with advanced experience treating trauma and stress-related disorders, mood disorders, substance use disorders, anxiety disorders, grief and bereavement, attention deficit disorders, adjustment disorders, relational dysfunction, and identity issues; Group therapy; Children and Families; LICSW License Supervision; Consultation

Applicable Training: EMDR (Level 1 and Level 2), TFCBT, NMT, FFT

I follow the Code of Ethics for the National Association of Social Workers (NASW). The Code of Ethics can be accessed from the website at: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English Any questions, concerns or complaints relating to the delivery of service by the therapist listed above, may be directed to the Board office:

WV Board of Social Work

PO Box 5459 Charleston, WV 25361

(304) 400-4980

www.wvsocialworkboard.org

By signing below, you confirm that you have reviewed and understand the Informed Consent for Psychotherapy document, which outlines the therapeutic relationship, confidentiality, telehealth procedures, and your rights and responsibilities as a client, and that you have been given ample opportunity to ask questions and that any questions have been answered to your satisfaction.

Client’s Name: 

Client’s Date of Birth: 

Client’s Signature:  

Today’s Date: 

IF THE CLIENT HAD ASSISTANCE REVIEWING AND COMPLETING THIS FORM, PLEASE INCLUDE:

Name of Person Assisting Client: 

Relationship to the Client: 

Phone Number for Person Assisting Client: 

Signature of Person Assisting Client: