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?
* 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.