Checklist – Informed Consent for Multi-Client Therapy *

Clarify the following with all parties before providing therapy services:
(This can then be placed in the file as documenttion of the discussion.)

	____   Name the  “primary” client(s) who will receive your therapy services:
		As expected by referral source _______________________________ As you will describe to third party payer ________________________ As clinically defined by you _________________________________
	____ What other parties will (or may) participate in the intervention(s )?
		As professional consultant(s)? _______________________________________ As **collateral(s)? __________________________________ ______________________________________________________
	____ Describe your role/relationship with each involved party?
		The primary client(s) ______________________________________________  **The “non-client” collaterals_________________________________________ Others (referring agency/organization, court, etc.) ________________ ______________________________________________________
	____ Do your roles involve any potential conflicts of interest?
		Do you have contracts with referral source that limit confidentiality? Must you report to “outsiders” about the process? What? To Whom?
	____ ***What are your rules about confidentiality and its limits?
		What are the possible uses of the information you obtain? What are your rules about disclosure of confidential information? Who will have routine access to records/information? Will you be providing information/reports to anyone routinely? What releases will you require before beginning clinical work? Will information shared privately be disclosed to others in couple/family? Are others expected to behave in a certain way about confidentiality?
	____ ****Will participants in group or family therapy also have rules about confidentiality and its limits?
		Rules about disclosure to each other outside the therapy room? Rules about disclosure to others outside the therapy room? Rules about confidentiality of outside interactions with e/o?
	____ ***What are the arrangements about fees/billing?
		What is the fee? _______________________________________ Who is responsible for paying it? ___________________________ Will you be sending statements? When is payment due? What happens if the bill isn’t paid? _________________________
	____ ***What is the nature and anticipated course of treatment/intervention? ____ Have you explained that changes in any one family member may affect the others? ____ Will sessions/meeting be audio- or video-taped? ____ Other

*  For considering how to define your relationship with all the parties involved in this case, read on this website: “Replacing ‘Who Is The Client?’ With a Different Ethical Question.”

** “Collaterals” participate in someone else’s therapy but are not themselves “therapy clients.”

***Details must be tailored to fit your actual policies and circumstances.  Expand list of choices as needed.