INFORMED CONSENT FORM

Inquire Counseling
Shaza Nessim, MACP, Provisional Psychologist

Welcome to my practice. This document will cover important information about my professional services and
policies. Please read this carefully, and let me know if you questions. When you sign this document it will
represent an agreement between us.

Psychological Services
Psychotherapy varies depending on the personalities of the client, clinician, and the particular problems you
hope to address. There are many different methods I may use to deal with those problems. It requires an active
effort on your part as well. In order for the therapy to be most successful, you will have to work on things we
talk about during our sessions. Psychotherapy can have benefits and risks. Because therapy often involves
discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger,
frustration and helplessness. On the other hand, you may experience positive feelings and notice significant
reductions in feelings of distress. There are no guarantees as to what you will experience.

Our first few sessions will involve an evaluation of your needs and we will develop a treatment plan to follow,
if you decide to continue with therapy. I believe that you should be a part of this process as I utilize a solution-
focused approach to therapy which focuses on a goal-oriented emphasis where the client is involved in every
step of the their treatment. At the end of the evaluation, I will notify you if I believe whether I am or am not the
right therapist for you and take next steps accordingly. You should evaluate this information as well to
determine whether you feel comfortable working with me. If you have nay questions about my procedures, we
should discuss them, whenever they arise.

Benefits and Risks of Telepsychology

Telepsychology refers to providing therapeutic services remotely using telecommunication technologies, such
as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can
engage in services without being in the same physical location. This can be helpful in ensuring continuity of
care. Especially during times of pandemic when mental and physical health are very important, telepsychology
allows the client and clinician to continue services without increasing transmission risks. It can also be more
convenient and takes less time. Most research shows that telepsychology is as effective as in-person therapy,
however some clinicians and/or clients feel there might be something lost from non-verbal information.
Although there are benefits to telepsychology, there are also some risks including:
o Risks to confidentiality: Since the sessions are not held in a private office, there is a potential for
other people to overhear sessions if you are not in a private place during the session. From my
end, I will take reasonable steps to ensure your privacy, but it is important for you to do so as
well by finding a place that is private.
o Issues related to technology: At times technology may stop working during a session, other
people might be able to access our private conversation, or unauthorized people could access
stored data.
 o Crisis management and intervention: If a client displays that they are currently in a crisis
situation, I would usually recommend seeking face-to-face support and intervention. If a crisis
situation is identified during intake, we will develop an emergency response plan before
engaging in telepsychology to address potential crisis situations that may arise during the course
of our sessions.

Electronic Communication
We will decide together which kind of telepsychology service to use. You may have to have a certain computer
or cell phone system to use the services agreed upon. You are solely responsible for any cost to you to obtain
any necessary equipment, accessories or software to take part in telepsychology.

For communication between sessions, I only use email communication and/or text messaging with your
permission and only for administrative purposes. This includes things like setting and changing appointments,
billing matters, and other related issues. I cannot guarantee the confidentiality of any information communicated
by email or text, therefore I will not discuss any clinical information by email or text and recommend that you
do not either. I do not regularly check my email or texts, nor do I respond immediately, so these methods should
not be used if there is an emergency.

If the session is interrupted for any reason and you are having an emergency please contact 911 (or appropriate
authorities in your area). If the session is interrupted and you are not having an emergency, disconnect from the
session and I will wait two minutes and then re-contact you via the platform we have agreed to conduct therapy
through. If you do not receive a call back within two minutes, then please contact me via email or text message
to determine next steps.

Confidentiality
In general, the privacy of all communications between a patient and clinician are protected by law and I can
only release information about our work to others with your written permission. However there are a few
exceptions: if a judge orders my testimony in a legal proceeding, I must comply with that court order. There are
some situations in which I am legally obligated to take action and break confidentiality to protect others from
harm: if there is harm or risk of harm to a child [and elderly or disabled person], if there the patient threatens to
harm a third party, or if the patient threatens to harm himself/herself. I will attempt to fully discuss it with you
before taking any action.

I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of
our telepsychology. However, due to the nature of electronic communication I cannot guarantee that our
communications will be kept entirely confidential. I will try to use updated encryption methods, firewalls, and
secure back-up systems to help keep your information private, but there is a risk that our communications may
be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security
of our communications.
As a provisional psychologist, I am required to consult with my supervisor regarding cases in order to ensure
that I am doing the most effective job as a clinician. This requires me to disclose some personal information
during our supervision. My supervisor is required to abide by the same confidentiality requirements highlighted
above.

Session Meetings
All sessions will be 45 minutes in length, unless pre-arranged. I will usually schedule on session per week, at a
time we agree on, although some sessions may be more or less frequent. Once an appointment hour is
scheduled, you will be expected to pay for it unless you provide 12 hours advance notice of cancellation [unless
we both agree that you were unable to attend due to circumstances beyond your control]. I offer leniency for
one missed session with no notice.

Professional Fees
My hourly fee is $170. If we meet more than the usual time, I will charge accordingly. I charge this same hourly
rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of
less than one hour. Other professional services include report writing, email counseling, conducting
assessments, and preparation of treatment summaries.

Payment is expected for each session at the time it is held, unless we agree otherwise. If your account has not
been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of
using legal means to secure the payment. If you would like to use private insurance to cover the cost of sessions,
you may do so after completing payment with me. I do not provide direct billing at this time. Please ensure that
you review your health insurance and coverage policy thoroughly regarding providers that are covered under
mental health care.

Your signature below indicates that you have read the information in this document and agree to abide by its
terms during our professional relationship.

Client Name: Date:

Signature: