Disclosure and Informed Consent Statement
Jessica Kwerel, LPC, NCC
www.petlossdc.com
jessica@petlossdc.com
(202) 335-3019
Please read the below thoroughly and complete the fields below. If you would like to retain a copy for your records, please print before you submit.
Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client receiving counseling support, you have certain rights that are important for you to know about. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you, too.
counseling process
Counseling has both benefits and risks. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness), and/or the recall of unpleasant events in your life. Potential benefits include significant reduction of distress, and better problem-solving and coping skills. Counseling involves a significant commitment on your part, and you should feel comfortable with the therapeutic relationship. I can only counsel within the scope of my practice. If it is determined that you would be better served by a different provider, then I will make an appropriate referral.
confidentiality
Counseling involves the disclosure of sensitive, personal information. Communication between a client and mental health counselor is protected by law. Information provided by and to a client during therapy sessions is legally confidential and cannot be disclosed without your consent. You should know, however, that it is the law and my policy only to accept clients who waive confidentiality under the following circumstances:
If there is suspicion of child or elder abuse or neglect, past or present.
If I determine that you are a danger to yourself or to others.
If you provide written consent to release information.
If a court of law issues a legitimate subpoena or if you are involved in criminal proceedings.
If you elect to communicate with me by email at some point in our work together, I am able to respond briefly by return email, but please be aware that email and other electronic media are not completely confidential. I do not use an encryption program on email.
emergency services
My practice does not provide 24-hour emergency services. All phone messages and emails will be checked daily unless otherwise stated but are not for use in an emergency. In an emergency please call 911 or report to your local emergency room.
client’s responsibilities
As the client there are several responsibilities to make sure you are receiving the best services possible and benefits from these services. It is your responsibility to attend all scheduled sessions and call more than 24 hours in advance if you cannot attend your session. Repeated failures to attend sessions or to provide adequate rescheduling notice may lead to termination of services. Participating in counseling while under the influence of any mood-altering substances prevents any progress. If it becomes clear that you are under the influence, I will end the session and reschedule for a future date. A repeat occurrence will result in the termination of services (with referrals). Violent or threatening behavior may also result in termination of services and a police report.
credentials
Jessica Kwerel is a Licensed Professional Counselor in Washington, DC (#PRC15039), Colorado (# 0014760), Maryland (#LC13590) Virginia (#0701009407) and certified by the National Board of Certified Counselors (NCC #238583).
esignature
Per the ESIGN Act, your esignature is legally binding. By signing your name electronically below, you are agreeing that your electronic signature (or esignature) is the legal equivalent of your manual signature.
Client Electronic Signature