This Agreement and Consent Form for TeleCounseling Services, conducted by Doug Duncan, LPC, is being provided to you (client) in order to inform you about TeleCounseling and answer questions that you may have.
I understand that I must be at least 18 years of age to both consent and become a TeleCounseling therapy client.
As a client I understand that TeleCounseling is generally provided utilizing technology and that there may be problems with connectivity. If a disruption of service should occur, this problem is beyond the control of Doug Duncan and me (client), any scheduled or in process appointments will be re-scheduled.
I understand the laws that protect the confidentiality of my medical information also apply to TeleCounseling Services. As such, I understand all information concerning my counseling sessions are confidential with the exception of concern for the safety of myself or the safety of others (see 42 U.S.C. 290dd-3 and 290ee-3 for federal laws and 42 CFR part 2 for federal regulations.)
Doug Duncan is a licensed counselor in the State of Texas and has over 10 years of experience in counseling individuals. However, he does not guarantee resolution of any kind or assure success for TeleCounseling, either explicit or implicit. This means that there is no guarantee as to the outcome from the services offered by this counselor.
In addition, I understand that video/telephonic sessions may have limitations compared to in-person sessions. and if my counselor believes I would be better served by another form of psychotherapeutic services (e.g. in-person services) I will be referred to a psychotherapist who can provide such services in my area.
I understand that telecounseling therapy is not appropriate if I am experiencing a crisis or having suicidal or homicidal thoughts. If a life-threatening crisis should occur, I agree to contact a crisis hotline, call 911, or go to a hospital emergency room. I also understand that the counselor follows the laws and professional regulations of the State of Texas.
Video and Telephonic communication(s) between Doug Duncan, counselor and client cannot completely be 100% guaranteed due to the security of digital communication. However, ever effort to provide security has been taken by Doug Duncan
I have read and understand the information provided above. I have discussed it with my counselor and all my questions have been answered to my satisfaction.
I permanently agree to release and indemnify Doug Duncan, LPC from all suits, claims, and other actions originating from counseling provided through TeleCounseling
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Client Name (Please Print) ______________________________________ _________
Client Signature_____________________________ Date _______________________
___________________________ __________________Client Name (Please Print)
Client Signature_____________________________ Date ________________________
By signing above you agree and consent to Doug Duncan providing TeleCounseling services.