Informed Consent

I agree to receive treatment from René A. Jones, MSed, MFT (therapist) who received two masters degrees. One from Purdue University in Marriage and Family Therapy and the other from the University of Pennsylvania in Human Sexuality Education. I understand that the therapist is trained in treating couples, individuals, and families dealing with chronic illness, conflict, communication, domestic violence, loss/grief, self-esteem, sexual concerns, sexual abuse and sex therapy. I understand that the therapist does not have the ability to prescribe medication or treat most mental conditions that require prescriptions (schizophrenia), unless working collaterally with a psychiatrist. The therapist is not versed in treating drug and alcohol abuse. I understand that the therapist will refer me to another professional if a concern is beyond her skills or training.

I understand that my sessions with the therapist are confidential. That the information and my identity will not be revealed to anyone unless the follow circumstances are evident:

• I present a danger to myself (i.e. suicide or do physical harm)
• I present a danger to someone else (i.e. threats of homicide or physical harm)
• Child abuse or elder abuse is suspected
In these cases the proper authorities will be notified.

I understand that the therapist keeps all client files locked in a filing cabinet and that she is the only one with access to these files. I understand that I must sign a collateral agreement in order for any information to be exchanged between the therapist and other persons, such as physicians, psychologists, and/or family members.

I understand that I may terminate therapy at any time. The range of therapeutic treatment can vary depending on my concern, but the average time frame is about 12-16 sessions. This is also dependent on the consistency of visitation and commitment to therapy.

I understand that by entering therapy, other concerns and issues may be revealed that I did not previously know existed. I understand that I have control over what is discussed in therapy and that I do not have to address any issue that I do not wish to.

I understand that the therapist is versed in several approaches to therapy and practices a combination of systemic, emotionally focused, narrative, behavioral, functional, and solution focused depending on the client and the concern. I understand that these are all talk therapy approaches.

I understand that each session is $100 and that payment is due at the beginning of each session. If I need to cancel a session for any reason, the therapist requires 24 hours notice, prior to the session or I agree to pay the session fee. I also understand that if my check bounces I will be responsible for the service fee and session fee.

I understand that Couples Counseling Center is NOT a 24 hour service and in case of emergency I am to contact Crisis Services of Buffalo, a 24 hour agency, at 834-3131 or 911.

I understand that my signature signifies that I read and understand this information and give my informed consent to treatment.