Client-Counselor Consent Form
 

Any client who wishes to work with Christy Cuellar-Wentz, M.A. or Linda Semrau, M.A. must agree to the following conditions:  By filling out and returning our Client-Counselor Consent Form, you indicate that you understand and agree to the terms and conditions stated below:

• You agree that you have read the separate section on confidentiality, below, and you agree with the terms set out in that section.
• You understand that we are registered counselors practicing in the state of Washington and that our relationship is governed by the laws of the state of Washington.
• You agree that you are at least 18 years old.
• You agree to supply your true full name, address, and phone number on the Client Questionnaire.  You agree that all of the information you have provided in the Client Questionnaire is accurate, and that no important information has been deliberately omitted.  You understand that if any of this information is inaccurate, this may be a major limitation on our ability to help you. 
• While we are hopeful that our work together will be helpful to you, we cannot guarantee a positive outcome.  In addition, online therapy has only been in existence for several years, and researchers are only now beginning to study its effectiveness. Thus, you understand that engaging in online therapy with us is an experimental procedure.
• Based on what is known thus far, online therapy is not equally safe and effective for all individuals.  Thus, we reserve the right to choose whether or not to work with you online. We will work with you only if we feel that you are a suitable candidate.  In some cases, we will ask you to seek out the services of a mental health professional in your local area to for a face-to-face consultation and/or diagnostic assessment before agreeing to work with you online.  In addition, such a person can be called on for backup support in case of an emergency. 
• We cannot be held responsible for providing services to you in the event of a crisis or emergency situation. Because we are working long-distance, we do not have access to resources that we would otherwise have in such a situation. We will therefore require that you make an appointment with a local provider for a complete psychiatric evaluation that would be performed in an office.
• If, during our work together, we discover that you are not someone who can benefit from online therapy, we will discuss this with you immediately and will suggest that you seek out the services of a therapist in an office in your local area.
• If you are currently taking medication for depression, anxiety, or any psychological or psychiatric problem, we may ask you for the name, address, and phone number of the physician who has prescribed this medication, as well as your consent to contact this physician. 
• Like any other therapeutic modality, the effectiveness of online counseling depends greatly on how much of an investment of time and energy you are willing to make. Generally speaking, the more you invest in it, the more you will get out of it.
• We cannot be held responsible for breaches in provision of services to you that are due to our computers malfunctioning, and/or loss of electricity or Internet connection.  When you become our client, we will provide you with a phone number.  If you don’t hear from us when you expect to, please don’t hesitate to call us.  However, bear in mind that if there is an electrical outage, the phone lines may also not be working, temporarily.  
• Confidentiality In General: As registered counselors, we protect the confidentiality of the communications and contacts with all of our clients, including online clients.  We will only release information about our work to others with your written permission, or if we are required to do so by a court order or legal subpoena.  In addition, there are some situations in which we are legally obligated to breach your confidentiality and contact local law enforcement and/or social services authorities, in order to protect you or other people from harm.  These situations include the following: (1) If, in the course of our work together, we learn that a child, elderly person, or disabled person is being abused or is at risk for being abused, we are required to notify the appropriate protective services; (2) If, in the course of our work together, you tell us that you’re considering committing suicide or committing any other serious self-injurious behavior, or are considering violence against another person, we are required to notify the appropriate authorities to prevent such actions from taking place.  These situations rarely occur but if such a situation did occur, we would make every effort to discuss it with you before taking any action.
• Confidentiality Online:  It is never possible to guarantee 100% protection of the confidentiality of either email transmissions or phone calls. We will do everything possible to protect against any intrusions on our end, and we ask that you do the same.  It is our belief that the single biggest threat to confidentiality occurs as a result of sending messages where the confidentiality of your own messages sent to us, or ours sent to you is not secure.  If you send/receive emails from your work computer, your supervisor or superior may be able to or entitled to view these emails.  And unless you have your own password-protected email account at home, family members and others with access to your email account may be able to breach your confidentiality. 
• When using your home computer, please make sure that you are the only person with access to your personal email account.  In terms of confidentiality problems with telephone sessions, please understand that if you choose to use a cordless or cell phone during a phone session with us, someone with a scanner could possibly hear you talk.  Finally, there is always the remote possibility that a hacker will breach the confidentiality of our email transmissions.  To my knowledge, this has never happened to a therapist who is working online, e.g. confidentiality being breached by hackers, but there is always a first time.  To summarize, there are risks to your confidentiality online, as there are in an office setting as well.  However, we believe these risks to be extremely small assuming common sense is used and appropriate precautions are taken to protect emails sent and received. 
• The goal of our exchanges is to help you.  If either of us feels, at any time, that working together is not helpful enough to you, either of us is free to terminate our relationship at any time.   
• There are no other explicit or implicit commitments in our relationship.