Welcome to my practice. Before starting your therapy, it is important to know what to expect and to understand your rights and commitments. This consent form is an attempt to be as transparent as I can about the nature of the couples therapy process, so you are fully informed prior to starting the therapy. Although these documents are long, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
What to expect: Couples therapy is a process of identifying interaction and communication patterns that are negatively impacting the friendship, intimacy and fulfillment of needs of one or both partners in a relationship. Interventions to increase closeness and intimacy are used to deepen emotional connection and create changes which enhances the couple’s shared goals. Couples learn to replace negative conflict patterns with positive interactions and to repair past hurts.
Each partner will be expected to honestly examine their own interaction and communication styles, identity and express their own feelings, and are willing to attempt at experimenting with alternative methods of communicating and interacting. Each partner will be helped to further clarify their own values and their own level of commitment to the relationship and the outcome of the therapy may be increased satisfaction with the partnership or increased clarity about the decisions to moving forward.
Assessment: The first three sessions will be an assessment to determine if the couple is appropriate for couple’s therapy. The first session will last 75 minutes, after which, sessions will be 60 minutes. Longer sessions can be agreed upon before the session begins.
Cancellation policy: Payment is made after each session by cash, check or credit card. If both or one of you are prevented from attending our scheduled session and do not cancel the appointment at least 24 hours in advance, you will be charged the full session fee. Couples are seen together, so if one person is not able to attend, the appointment will be canceled. The practice for no-shows or late cancellation is standard practice in the field and takes into account that you are not just paying for services rendered, but reserving a time slot which I will not be able to offer to someone else on short notice.
Confidentiality: When you attend sessions, information you share is protected by strict confidentiality laws enforced both by the licensing board governing my license and state law. Without your written consent and permission, I cannot reveal whether you are a client of mine and cannot any discuss any information from our sessions with a third party.
The following are exceptions to this rule:
- If one of you pose an imminent danger to yourself, your partner, or a third person, I am obliged to disclose information to law enforcement personnel or hospital staff to keep you safe and coordinate care.
- If you talk about events that lead me to believe that a child under the age of 18 or an or an elderly or disabled person is at risk of emotional, physical, or sexual abuse, neglect, or exploration, I am required by law to make a report to Protective Services.
- If a judge in a court of law orders me to release information or if I need to respond to a lawfully issued subpoena.
The couple is the client: When you attend couples therapy sessions, the couple is considered “the client” and your records therefore belong to both of you. This means that except in the circumstances above, I will need a written consent from both of you to disclose any information from your record to a third party.
Because the relationship is the primary focus of couples therapy, both partners of a couple must be present for the couple’s session to begin. It is often not in the best interest of the couple to distribute time unevenly between partners or to have unplanned meetings with only one partner present. If one partner is late in arriving or does not show for the appointment, I reserve the right to delay the start of the session or to cancel the session if necessary.
Limitations to couples therapy: Couples therapy will only be effective in cases where both partners put in a good faith effort to work on their problems and their relationship. Deliberate dishonesty or deceit, unwillingness to introspect and take responsibility for one’s actions, or lack of interest and failure to engage in the couples therapy process by one or both partners will undermine the therapy.
Couples’ therapy is not advisable in the following situations:
- If there is active alcohol and/or drug addiction on the part of either or both partners, from either partner’s perspective.
- If there is serious violence in your relationship, threats by one or both partners that serious violence might occur, or fear of such serious violence on the part of one or both partners
- If either partner currently has an untreated major mental illness (schizophrenia, recurrent psychotic depression, or bipolar/manic-depressive illness.) This does not include past, successfully treated psychotic episodes.
- If there is an undisclosed, current affair that you are not willing to disclose (such secrets predict marital therapy failure)
- If either partner is currently experiencing suicidal or homicidal thoughts, or has a history of serious harm inflicted on him/herself or another person.
- If the partners engage in litigation that interferes with the therapeutic relationship.
No secrets policy: As a therapist who is entrusted with information from both partners of a relationship, I have a policy of “No Secrets”, which means that I cannot agree to protect secrets of either partner from the other person. I cannot provide my best therapy if I am asked to keep secrets from one of the partners.
Between-Session Contact: Please contact me at 713-522-9323 or email me at: lind@lindbutler.com for scheduling or administrative questions. I will typically return calls within 24 hours. I do not discuss clinical matters by phone or without an appointment. Any phone or written communication between meetings will be reviewed with both partners at the beginning of the next session.
In the event of a clinical emergency, such as acute thoughts of harming oneself or others or experiencing a traumatic life event, you may leave a message on my confidential voicemail indicating the nature of the emergency, and I will return your call as soon as possible. If you feel you are in imminent danger to yourself or others or if you feel that your health is at risk, please visit your nearest emergency room; dial 9-1-1; or call the National Crisis Lifeline, day or night for free immediate support at 1-800-273-8255.
Termination by the therapist: I reserve the right to terminate treatment under certain conditions which compromise my ability to provide effective services, the client’s ability to benefit from services, or when it is legally and/or ethically appropriate to do so. Such circumstances include, but are not limited to:
- Three missed appointments or late-cancellations within a six-month period
- Non-adherence to the treatment plan
- Non-compliance with practice policies & procedures
- Refusal to accept recommendations for a higher level of or supplemental care
- Behaviors that are disrespectful, devaluing, threatening, or otherwise inappropriate.
- Conduct that compromises the therapeutic relationship
- Conduct that poses an immediate risk of harm to any person
- Misrepresentation or omission of pertinent clinical information
- Non-payment of fees
We, the client, understand and consent to the above terms, and agree to initiate treatment.