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Couple Informed Consent Form

YOUR LETTERHEAD

DOCUMENTATION OF
INFORMED CONSENT FOR TREATMENT:
COUPLES THERAPY

We understand that couples therapy begins with an evaluation of our relationship, past and present. While Dr. Miller is deciding whether she is the appropriate therapist for us, we will decide whether we wish to begin couples therapy with her. We understand that because of the commitment of time and money, plus the potential impact on us and others (see below), it is important to make an informed choice for a couples therapist.

We have read and understand the potential limits of confidentiality, including those imposed by Dr. Miller’s policies and by state law, and we have received a copy to keep. [If we have dependent children, we have read and understood the potential limits of confidentiality regarding access to records in child custody cases].

We understand that information discussed in couples therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners. We agree not to subpoena Dr. Miller to testify for or against either party or to provide records in a court action.

We understand all policies as described on the PATIENT INFORMATION sheet and accept them as conditions for entering into couples therapy with Dr. Miller. We understand the limits and benefits of using insurance to pay for couples therapy. If we use insurance, we agree to provide all information needed to comply with insurance regulations. We understand that if we use insurance, Dr. Miller will not retain control over information provided to the insurance company.

We have been given the opportunity to ask questions and discuss confidentiality and disclosure policies with Dr. Miller. We understand that while working as a couple, anything either of us might say to Dr. Miller individually, whether by phone or in an individual session, will be held confidential and will not be shared with the spouse/partner without the individual’s consent. [Alternative: . . . anything either of us tells Dr. Miller individually, whether on the phone or in an individual meeting, may not be held as confidential, and at Dr. Miller’s discretion may be shared with the spouse/partner during a subsequent couple session.] *

We agree to share responsibility with Dr. Miller for the therapy process, including goal setting and termination. By entering into couples therapy, we accept that we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. We understand that the changes one or both of us makes will have an impact on our partner and on others around us. We accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. [This is especially true if we have dependent children.]

[Dr. Miller has explained that her therapeutic focus in couples therapy is on preserving and enhancing the relationship rather than a focus on individual happiness.
OR. . . If remaining together is harmful to one or both partners, the focus will be on facilitating an amicable separation.]
*

We agree to pay for all services provided by Dr. Miller, including any charges not fully reimbursed by the insurance company. We understand that no insurance company will pay for missed sessions, and we agree to Dr. Miller’s policy of charging if we fail to cancel appointments in advance.

By signing below, we agree to accept mental health services from Dr. Miller and accept full responsibility for payment for such services.

Patient_______________________________ Date______________________ Patient_______________________________ Date______________________
NOTE: This is a sample form, designed for training purposes.
To the best of our knowledge, it is consistent with Virginia laws and regulations.
However, for use in your own setting, this form must be personalized
to reflect your state’s laws and your own actual policies.
(*Choice of sentences must reflect your own actual practices in working with couples.
If neither sentence applies, you should supply wording to describe your approach.)

Drafted for The Center for Ethical Practice, Inc.
by John T. Schroll, Ph.D.