Informed Consent For Clinical Consultation (Consultant-Consultee Contract)

Letterhead

Contract for Clinical Consultation

I wish to receive consultation services from _____________________.

I understand that these consultations do not constitute clinical supervision and that I remain completely responsible – ethically and legally – for the decisions I make in my own clinical case situations. My consultant will provide me with an opportunity to discuss clinical cases and issues about which s/he may have some expertise, and s/he may help me consider options for responding, but the comments made for my consideration are not supervisional mandates.

I also understand that although we may sometimes need to discuss personal issues that may be relevant to my clinical work, these consultation services do not constitute psychotherapy.

I understand the potential limits of the confidentiality of this relationship. To the extent possible, my case presentations will provide no identifiable patient information. However, I understand that if I provide identifiable information about a situation regarding which my consultant has an ethical or legal obligation to report confidential information, s/he will inform me at the time and will give me the opportunity to make the report myself.

I understand that if my consultant becomes aware that s/he knows or has a prior relationship with the presented client(s), or if she believes she has a potential conflict of interest in her relationship with me, she will notify me of that fact immediately and will cooperate in helping me find a different consultant.

I agree to the fee of $_________ per one-hour consultation session, payable at each meeting.

_______________________________________________
(Name of Consultee — please print)

_________________________________________
(Signature)

___________________
(Date)

*NOTE: This is a sample form, designed for training purposes.
For use in your own setting, this form must be personalized
to reflect your actual policies.