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: August 05, 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. These methods should not be used for emergencies or urgent clinical concerns. While reasonable safeguards are used, electronic communication carries inherent privacy risks. 

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

To protect your confidentiality and privacy, I do not accept friend requests or other personal connections through social networking sites.

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.

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: