Service Agreement and Informed Consent for Couple
I look forward to working with you as your Counselor and Imago Therapist. I am deeply committed to helping you create and achieve your vision for your life and your relationship.
Please read this document carefully. The purpose of this document is to familiarize you with the benefits and risks of Imago Therapy and the unique aspects of the services I provide. At the end of this document, you will be prompted to “Accept” this agreement indicating you have read, understood, and fully agree to give your informed consent and compliance with these guidelines and parameters before starting counseling and therapeutic services as a couple.
OUR WORK TOGETHER
I am a Licensed Professional Counselor (LPC) in the state of Missouri. I am a Certified Imago Therapist with Imago Relationships International, as well as a nationally registered and board-certified Art Therapist (ATR-BC) with the Art Therapy Credentialing Board (ATCB). I have been a therapist since 1993 and became licensed in the state of Missouri as a Professional Counselor in 2007. In 2007, I decided to specialize in relationships and carefully researched certification programs beyond my Master of Science degree that would best qualify me to help couples. I chose the Imago theory developed by Dr. Harville Hendrix due to the effectiveness and practical applicability of the interventions. The theory is consistent with my own belief that each individual has an inner propensity toward growth, healing, and loving relationships, and the purpose of therapy is to provide guidance and support.
During Imago Therapy sessions, you will experience and learn a model for empathetic communication that will improve your connection in important relationships, while benefiting from the guidance of a seasoned therapist. While each couple's goals are unique, you can expect to gain a new understanding of your interactions, your own needs, and the needs of your partner. You will acquire new skills to improve communication, soothe yourself, soothe your partner, and work as a team toward a joint vision. Couples I work with often report things like learning to quickly recover and reconnect when disagreements or triggers occur, and feeling heard and valued by their partner. All types of relational therapies have risks including making you more aware of uncomfortable feelings and/or unresolved childhood issues. However, I have found most people find the structure of Imago Therapy and the support of an Imago Therapist to be a particularly safe way to release and explore feelings and triggers and find new ways to access inner and outer support.
Imago Therapy will give you a new experience of communication. You will have the opportunity to begin integrating that experience into your daily life. With the practice obtained during sessions, you will find the quality of your interactions greatly improved. You will gain insight into your patterns and beliefs. During sessions, we will strive to find the behaviors or actions you can take to support your vision for your life and your relationship. The benefits you experience will be a direct result of your intentionally implementing new insights into your daily life. I will help you both identify and pace your transformation.
I will provide you an emotionally safe and encouraging environment for exploration. Your part will be to cultivate openness and honesty with yourself, as well as your partner. You agree to commit yourself to grow and establish intentions that are truly meaningful to you, as well as actions that are supportive of the relationship.
If you are receiving Imago Couples Therapy, please understand that both you and your partner must attend all sessions together. Learning how to honestly communicate emotions, thoughts, opinions, and beliefs requires risk-taking, patience, and commitment, and is best achieved through the collaboration of both partners.
EMERGENCIES OR NEEDS BETWEEN SESSIONS
If you are having a clinical emergency and feel safe to wait for me to return your call, you may call me at 816-359-1885. If you are experiencing a clinical emergency that requires immediate assistance, you agree to obtain support from one of the following available sources by calling your physician, calling your psychiatrist, calling Access Crisis Mental Health Intervention 888-279-8188, going to your local emergency room, or calling 911.
THE SYSTEM OF MONEY
Imago Couples Therapy is $110.00 per hour. You may choose to commit to ten hours of therapy and pay in full $1,000 for a savings of $100. You may pay the balance of the $1000.00 prior to the first session, at the first, or at the second session. Experts recommend a minimum of ten to twelve sessions to solidify a lasting change in the quality of your relational interactions. I have found that couples report significant shifts within a few sessions and are interacting in new ways consistently around six sessions.
PRIVATE CLIENT ACCESS
You will have access to a secure and confidential “Private Client Website.” You will be given a unique username and password. As a couple, you will share your username and password and will have identical access to information and logs from this therapist. You may access this “Private Client Website” area to access resources and complete documents. I will provide you with the access information and further instructions once we begin our work together.
I agree to have access to a private client website, which will include receiving email notifications.____________________________________
CONFIDENTIALITY
Please carefully read the Notice of Privacy Practices regarding release of information regarding services you receive from me and your individually identifiable information.
The Notice of Privacy Practice is provided under "Documents" in the Private Portal or you may request a paper copy at any of your in-person sessions.
Professional Records
Your progress is documented in private logs that you will have access to through the "Private Client Website." This is a unique benefit that I provide and I have found it to effectively help couples stay on track with the work together and maintain momentum. You will receive a notification of new logs written by this therapist in the email you have provided.
I am unable to guarantee that using electronic communication is confidential. Sensitive information like intake questionnaires and goals for therapy are secure in the Private Client Portal based on username and password and secure pages. The security of the portal is limited based on your intentionally or unintentionally giving access to your password, and/or access to your computer while in the portal, and in these cases confidentiality cannot be guaranteed by this therapist. Additionally, the system does generate email reminders, notifications, and Affirmations and Tips. These emails are not personal in nature, however, anyone who has access to your email may gain knowledge of your receiving email and services from my office.
I agree to receive Relationship Affirmations and Tips through my email.____________________________________________________
If you have concern about electronic communication, please notify me to eliminate this aspect of your service. Otherwise by accepting services from me you are agreeing to the enhanced benefit of the education and support you will receive through the "Private Client Website" and the weekly Affirmations and Tips.
