We feel it is important that, as our client, you are fully informed about the therapy services you will be receiving. Your signature below indicates that you have received, read, and understand the practice policies of this therapy site in helping you make an informed decision about entering therapy.

  1. I understand that my therapist will provide assessment and therapeutic services within the scope of his/her license. I understand that my therapist will work with me to develop a treatment plan and treatment will be formulated to resolve my presenting problem(s) as quickly as possible. I understand that I must cooperate with my therapist in the treatment process, carry out therapeutic homework assignments and follow through with any medical treatment, as prescribed by my physician.
  1. I understand that my Innovo Counseling, LLC therapist may discuss general case information with other Innovo therapists while respecting my confidentiality. However, the other therapist will not be responsible for the case direction.
  1. I understand that my therapist is bound by the Code of Ethics of the Department of Mental Health of Missouri set forth by their respective fields of focus and that I can request a copy of those ethics at any time.
  1. I understand that, except under specific circumstances mandated by law, communication with my therapist(s) will remain confidential as will any records regarding the therapy process unless I sign an Authorization & Request for Release of Confidential Information or a Privileged Communication Form authorizing access to the information before any file information will be released in accordance with the Missouri laws. If more than one family member participates in a session, each and every participating family member must consent prior to the release of the file information. Where a minor is receiving services, the appointment of a guardian ad litem may be necessary prior to the release of the minor client’s information. The client’s family members are not entitled access to client information just because they are family.
  1. I understand that, in accordance with state regulation and/orprofessional ethics, specific circumstances require my therapist(s) to break confidentiality and report information obtained as a result of the therapy process. Those circumstances exist when: a) a therapist believes a client may be a danger to him or herself or to others; b) the therapist believes that a child, elderly or disabled person may be a subject to abuse or neglect; and, c) when a court order exists that information regarding the therapy process be provided. Innovo Counseling, LLC therapists are mandated reporters.
  1. Innovo therapists do not knowingly accept court-related cases. I agree that I am not involved in a court-related case regarding the circumstances in which I am seeking therapy for. I understand that, for court appearance and or court case preparation for cases and consultations with legal and medical professionals, I will be charged a fee of $300 per hour – plus expenses - for court preparation (including paperwork, travel, testimony, time, or any other action requiring the therapist’s attention).
  1. I understand that there are risks and benefits associated with therapy and have discussed those with the therapist(s). Risk include, but may not be limited to the following concerns:
  2. The change process may bring with it a significant amount of discomfort before any improvement is noticed.
  3. Unpleasant memories may resurface resulting in an increase in depression, anxiety, fear, anger, frustration, loneliness or helplessness while attending therapy sessions.
  4. Therapy may not be effective resulting in no improvement or deterioration.
  5. Others may judge me for attending therapy.
  6. Therapists may need to refer me to other therapists or services when they are concerned that Innovo Counseling, LLC treatment approaches are not helpful, or are not providing enough help. I understand and accept this dilemma.
  7. Marriages and relationships may not improve, or even get worse.
  1. I understand that the financial policies of the therapy site and agree to pay $______per hour for the therapy at the end of each session. Every fifteen minutes past the 50 minute scheduled appointment will result in additional charges.
  1. I understand that, a therapy hour is a 50 minute session. If, I come late for session for any reason, I will be charged for an entire therapy hour of 50 minutes and the session will end at the appointed time. I understand that if a session goes over the 50 minute session time, I will be pro-rated an additional charge based on 15 minute increment based on Innovo Counseling, LLC fee.
  1. Cancellation policy. I understand that, I have to give my therapist(s) at least a 24 hour (normal business day) notice of a cancellation of a therapy session. If not, I will be charged my normal fee for not following the cancellation policy.
  1. I understand Innovo Counseling, LLC does not accept any form of insurance nor do they submit any claims to insurance companies.
  1. I will receive a receipt for payments made for services which I may use for tax and medical expense deductions. I agree to ask for a receipt if the therapist does not offer one and I need it. I understand that Innovo Counseling, LLCdoes not provide any other record during or after service for tax purposes.
  1. I understand that I am responsible for keeping my scheduled appointments and understand that the failure to do so my result in my care being terminated. I understand that if there is no session activity or phone contact recorded in my file for a period of 3 weeks, my file may automatically be closed. I understand that, in some circumstances, my file can be reopened upon completion of a new intake and payment of any balance due. I understand that if I miss more than three (3) consecutively scheduled sessions in a ten (10) week period, my file will be closed.
  1. I understand that my records and related files financial files are kept in a locked file cabinet and/or securely encrypted in electronic medical records. I understand records are maintained for 5 years after discontinuing services for adults and until age 28 in the case of minors, and may be stored, scanned or manually entered into a computer for storage at any time now and in the future. I understand at the end of that period the records are destroyed in a manner that assures the confidentiality of the information unless I request otherwise, in writing, prior to the destruction of records. I may review my own records only after giving a written notice, and allowing 48 business hours for records to be retrieved. I may not review records sent to Innovo Counseling, LLC (even when placed in my file) from another facility. I understand that my records will not be made available to others without signed authorization to release information and payment for the records prior to releasing them. Special rules relating to release of treatment records containing information regarding drug and alcohol abuse: CFR 42, PART 2 prohibits disclosure of such information without written consent of the client and only to the extent specifically authorized. A general release for medical or other information is not sufficient. Use of information in records for criminal investigations and prosecution is prohibited.
  1. I agree to pay for any damages to, or theft of, property in this office by me or anyone for whom I am legally responsible. I agree that neither Innovo Counseling, LLC nor Innovo therapists are responsible for any personal property or valuables I bring or leave in the facility. Behavior threats or police involvement may result in the immediate discharge of client after review from the Director of Counseling.
  1. I understand that Innovo Counseling, LLC is not a mental health facility and does not have the staff to maintain 24 hour care. In life threatening emergencies, I should dial 911. For crisis situations, such as thoughts of harming self or others; I can call my therapist at 816-866-0412. I understand that staff may not be able to take the crisis call, and I am responsible to put safety measures into place.
  1. EMERGENCIES: In emergencies, I would like the following person contacted:

Name: ______

Address: ______

Phone: ______

I waive any confidentiality rights in an emergency, and understand that my therapist, or member from Innovo Counseling, LLC may contact this person and I agree to hold Innovo Counseling, LLC harmless.

  1. CLIENT RIGHTS: All clients have rights concerning their therapy. I have:
  • The right to be treated with consideration and respect.
  • The right to expect quality services provided by concerned, competent staff.
  • The right to be fully informed and to ask questions about my therapy, statement of purposes, goals, techniques, rules of procedure, the limits of confidentiality in the therapy setting, the potential dangers of the services to be performedand all other information related to or likely to effect the continuous therapeutic relationship.
  • The right to specify and negotiate therapeutic goals and to renegotiate them when necessary.
  • The right to obtain my case file and to have the information explained clearly and directly.
  • The right to complete confidentiality, except in mandated circumstances, and that no information will be released without written consent.
  • The right to be fully informed of therapy fees and payment records.
  • The right to refuse any recommended services and be advised of the consequences of this action.
  1. I understand that there are numerous forms of psychotherapy that vary by underlying theory, methods employed, time commitment and cost and Innovo Counseling, LLC will attempt to provide treatment that is realistic in all areas. I understand that research has failed to demonstrate that any one form of psychotherapy is necessarily more effective than any other.
  1. NO SECRETS POLICY: I understand that Innovo Counseling, LLC maintains a “no secrets” policy in couple’s and family therapy. This means the client must disclose all therapeutically relevant information to all parties (adults) in therapy. This is especially true regarding areas of unfaithfulness.
  1. HOLD INNOVO COUNSELING, LLC HARMLESS: I hereby release, waive, and hold harmless Innovo Counseling, LLC, its curators, officers, agents, volunteers, interns, and employees, from and against any and all claims, demands or causes of action of any type whatsoever, including property damage, personal injury or death, arising out of or in any way related to my participation in the counseling process. Furthermore, I hereby agree that my participation in the counseling at Innovo Counseling, LLC is exclusively for my own personal benefit and that I will not involve Innovo therapist in any court related matters as references, character witnesses, and/or any other court related matters. I assume full responsibility for my court related matters and will not involve InnovoCounseling,LLC for any court related participation on my behalf.

This agreement is binding, upon the members of my family, spouse, my estate, heirs, administrators, personal representatives, assigns and any other person entitled to act on my behalf. This agreement shall be construed under the laws of Missouri.

I have read and understand the terms of this Release and Hold Harmless Agreement and agree to all terms and conditions. I am of lawful age (above 18 years old) and legally competent to sign this waiver and release, and I have signed this document as my own free act.

  1. EMAIL COMMUNICATION: My therapist and I can communicate from time to time through the use of emails. I understand that when I leave a phone message with this therapist, it may be converted to an email message and sent to the therapists. Although unlikely, it may be possible for others to see information sent through email. Innovo Counseling, LLC recommends careful consideration of any messages sent by way of cell phone or email communication. I understand my therapist is required to keep a copy of the email, or will keep some form of record of any and all communication and meetings that occur between us in my file. Having been made aware of the above mentioned information, I (please place a mark in either the “do” or “do not” area) do___ do not ___ give permission for my therapist and I to communicate through email.

23. CONSENT TO TREAT MINORS: I warrant that I am a custodial parent of the below named minor child(ren). I hereby give permission for them to receive counseling. I acknowledge that I am aware of the mandated reporting laws in the State of Missouri. I understand that I can withdraw the permission to treat my child at any time. I will assume responsibility to notify my child’s other parent that counseling has been initiated and will take sole responsibility in arranging for the payment for all counseling services for my child.

Minor’s Name / Date of Birth / Minor’s Name / Date of Birth
Minor’s Name / Date of Birth / Minor’s Name / Date of Birth
Minor’s Name / Date of Birth / Minor’s Name / Date of Birth

My signature below indicates that I give my full and informed consent to receive individual, marriage and family therapy services from this site for myself and/or children. I fully understand and agree with the items in this informed consent agreement including payment arrangements. I agree that I have received a copy of this informed consent contract for my personal records. I understand that not abiding by these policies may lead to termination of this therapeutic agreement and/or referral to another professional.

Client Signature / Date / Client Signature / Date
Client Signature / Date / Client Signature / Date
Therapist Printed Name and Credentials:
Therapist Signature: / Date / Therapist Printed Name and Credentials:
Therapist Signature: / Date

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