Informed Consent Policy

Informed Consent for Psychotherapy

Melanated Womens Health, LLC
1500 Walnut Street 
Philadelphia, PA 19102

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with your Therapist. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
The Therapeutic Process You have taken a very positive step by deciding to seek therapy for yourself or your child. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of emotions attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. Therapists cannot promise that your or your child’s behavior or circumstance will change. However, we can promise to support you or your child and do our best to understand repeating patterns, as well as help you clarify what it is that you want for yourself or your child.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1. If a client threatens or attempts to suicide or otherwise conducts him/her/them self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, your Therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and we do not wish to jeopardize your privacy. However, if you acknowledge your Therapist first, your Therapist will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

We are governed by the laws of the State Board of Pennsylvania.

BY STARTING SERVICES I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Have Questions?