INFORMED CONSENT FOR DR. JOHN HANEY, PhD.

You are entering a therapist-client realtionship with me, Dr. John Haney, Ph.D.

The counseling relationship carries communication privileges and rights to confidentiality. I want to assure you that what you say and discuss in here will remain confidential. There are some situations, however, in which I am required by law and code of ethics to break confidentiality. Those situations include:

  1. If you report a situation in which a child, elderly person, or anyone who cannot otherwise protect themselves is being neglected, or physically or sexually abused.
  2. If you represent a harm to yourself.
  3. If you represent a harm to someone else.
  4. If my records are subpoenaed by the courts for purposes of litigation.
  5. If you grant permission for your records to be sent to another Mental Health professional or some other kind of professional.

By signing this Informed Consent, you indicate that you recognize the limits of confidentiality. You understand that you have the right to terminate counseling at any time.

Fees: Initial interview - $150.00, thereafter $135.00 per couple; $125 for an individual. Sessions are 50 minutes long and start on the hour.

If for any reasons you must miss a scheduled appointment you agree to call 24 hours prior to the appointment to cancel it or be responsible for paying the fee for the missed appointment.

If you are comfortable with the terms of confidentiality, please sign this form. I will keep it in your file, and if you wish, I will provide a copy for you.