Informed Consent for Couples Therapy – Download



To be signed in addition to individual Service Agreement and Privacy Policy Forms

We understand that couples therapy begins with an evaluation of our relationship, past and present. While our therapist is deciding whether they are the appropriate therapist for us, we will decide whether we wish to begin couples therapy with them. We understand that because of the nature of the therapeutic relationship, commitment of time and money, plus the potential impact on us and others (see below), it is important to make an informed choice for a couple’s therapist.

We have read and understand the potential limits of confidentiality, including those imposed by White Cloud Therapeutic Services, LLC policies and by state law, and we have received a copy to keep. If we have dependent children, we have read and understood the potential limits of confidentiality regarding access to records in child custody cases.

We understand that information discussed in couples therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners. We agree not to subpoena our therapist or any representative or therapist of White Cloud Therapeutic Services, LLC to testify for or against either party or to provide records in a court action.

We understand all policies as described on the SERVICE AGREEMENT form and accept them as conditions for entering into couples therapy. We understand the limits and benefits of using insurance to pay for couples therapy. If we use insurance, we agree to provide all information needed to comply with insurance regulations. We understand that if we use insurance, our therapist will not retain control over information provided to the insurance company.

We have been given the opportunity to ask questions and discuss confidentiality and disclosure policies with our therapist. We understand that while working as a couple, anything either of us tells our therapist individually, whether on the phone or in an individual meeting, may not be held as confidential, and at our therapist’s discretion may be shared with the spouse/partner during a subsequent couple session.

We agree to share responsibility with our therapist for the therapy process, including goal setting and termination. By entering into couples therapy, we accept that we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. We understand that the changes one or both of us makes will have an impact on our partner and on others around us. We accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them.

Our therapist has explained that their therapeutic focus in couples therapy is on preserving and enhancing the relationship through a focus on individual happiness. However, if remaining together is harmful to one or both partners, the focus will be on facilitating an amicable separation.

We agree to pay for all services provided by our therapist, including any charges not fully reimbursed by the insurance company. We understand that no insurance company will pay for missed sessions, and we agree to White Cloud Therapeutic Services’ policy of charging if we fail to cancel appointments 24 hours in advance.

In addition, this agreement shall serve as a contract between the interested parties that no party shall attempt to subpoena the therapist’s testimony or their records for a deposition or court hearing of any kind for any reason.

We acknowledge that the goal of therapy is the amelioration of psychological distress and interpersonal conflict, and that the process of therapy depends on trust and openness during the therapy sessions.

Therefore, it is understood by us that if we request therapeutic services, we are expected not to use information given during the therapy process for our own joint or individual legal purposes or against any other individuals in a court or judicial setting of any kind.

By signing below, we agree to accept mental health services and accept full responsibility for payment for such services.


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Client_______________________________ Date______________________

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