At times we all experience challenges that effect our mental health. There are times when you need to address these challenges with a kind, compassionate, non-biased, intuitive listener, and that’s me. I treat everyone with dignity and respect. My counseling style is warm and interactive. My approach combines cognitive-behavioral, humanistic, psycho-dynamic, dialectical behavioral therapy and rational-emotive counseling. I have been a psychotherapist for 12 years. I have worked with clients with a wide range of concerns including depression, anxiety, relationship issues, parenting problems, career challenges, OCD and ADHD. I also have helped many people who have experienced physical trauma or emotional abuse. I believe in a team approach. We will develop treatment plans together to address your specific needs and concerns.
Listed below is a client consent form and disclosure:
CLIENT INFORMED CONSENT
I understand that the service provided through BetterHelp is not intended for crisis situations and urgent needs. While my therapist, Jan Gunn, LMHC (License # MH 9798) is a licensed therapist in the state of Florida, Better Help services and/or online or text-based services may not be the best avenue for me to receive mental health care. If the use of this site or online services are not appropriate for my situation, I understand that my therapist will assist in providing me with additional options of in-person referrals where I can obtain care.
Verification of Identity and Location at the time of session:
I understand and agree to provide my therapist with a copy of a valid photo identification, such as a driver’s license, state ID, or passport at the start of our work together. This is to verify my identity including legal name, date of birth, and home address.
If my address on the submitted ID is not included or not current, I will provide my clinician with my current correct address.
I agree to provide my therapist with a phone number to reach me in an emergency.
I understand that for safety reasons, my therapist will NOT meet with me in a moving vehicle, and that failure to inform my therapist of this information at the start of my session will result in the session being cancelled.
In a crisis situation, I agree that I will either:
TEXT: You can text the Crisis Text line by texting “Home” to 741-741
PHONE/VOICE: Call the Suicide Prevention Crisis Hotline via phone at (800) 273-8255
You can also call your psychiatrist for assistance or 911
IN PERSON: Go to your nearest emergency room for in-person help if you are in immediate crisis.
I understand that my confidentiality is fully protected by law with the exceptions of these FOUR circumstances:
If my therapist has concerns or suspicions of abuse or neglect of a child, elderly person, someone with a disability, or someone otherwise unable to care for themselves
If I present as a risk of harm to myself or others in the professional judgement of my therapist
If my therapist is legally compelled through subpoena or court order in any court proceedings regarding my care (this is rare, and if it were to happen, we would discuss it thoroughly.)
If I choose to sign a Release of Information form
I don’t have immediate access to the information you shared when you registered, and I have an ethical and legal responsibility to know how to contact you in case of emergency. Your emergency contact person will only be contacted in the event that I am concerned for your safety and am unable to reach you by any other means.
Full name:
Date of birth:
Address:
City, State, and Zip Code:
Telephone number:
Name of Emergency Contact Person:
Relationship to Emergency Contact Person (friend, spouse, parent, etc):
City of Residence:
Emergency Contact Person’s Phone Number:
I have read, understand, and agree to the Client Terms of Service at https://www.betterhelp.com/terms/ 10
This includes understanding and agreeing that:
My BetterHelp therapist cannot provide, verify, or produce reports related to clinical diagnosis of a mental health condition. While trained to do so, services of this nature must be provided outside of the BetterHelp site/services at the discretion of my provider.
My BetterHelp therapist cannot provide proof of attendance at, or reports regarding progress in, use of the site or services provided through the site. This includes documentation for court, custody agreements, employers, or any other party.
My BetterHelp therapist cannot provide letters of support for Emotional Support Animal designations (or ESA’s.)
I understand that I can seek out online therapy with Jan Gunn, LMHC or another clinician OUTSIDE of Better Help if I have needs for clinical diagnosis, biopsychosocial assessment with diagnosis (including psychological testing), or referrals for treatment that come from the legal system, child welfare services, or my employer, and may require documentation or proof of attendance.
Privacy of Sessions
If having a “live” session with my therapist, my therapist will ensure my privacy by using noise-cancelling headphones and being alone at the time of sessions. I understand that I am solely fully responsible for the privacy in my own environment for meetings. To ensure the greatest privacy, my clinician recommends:
Ensuring that I am alone in the room I am meeting
Using headphones for phone and video sessions whenever possible
Muting the microphone (or turning off apps) that listen to my environment, such as Amazon Alexa, Google Home, Siri on Mac devices, or Bixby on Samsung devices
If possible, placing a Bluetooth speaker or device outside of the space I am in that plays “white” noise or music to mute any options of hearing me speak during sessions.
Scope/Location of Practice
I understand that my therapist is ONLY able to work with clients who reside in Florida full time. This is a legal requirement for my clinical license to practice, and I will not jeopardize licensure status by violating this rule. If you are quarantined out-of-state, traveling, working, or residing at college outside of Florida, please let me know at the start of our work together.
Risks and Benefits of Counseling:
First and foremost, I can’t help if you aren’t here! In making an appointment, you are committing to that time for yourself to the exclusion of others. If you must cancel an appointment, you must provide no less than 24 hours’ notice unless there is an emergency. Failure to cancel in advance may result in changes to the type or frequency of sessions your clinician is able to offer.
To gain the most from the therapy process, it’s helpful if you are honest about your commitments to self-examination, understanding, and our relationship. This includes any concerns you may have regarding services or with me. I want to serve you well and appreciate any feedback you may have that will help me to do so.
Unwise applications of new learning are a common risk in therapy (e.g. being too harsh when learning to assert yourself) as well feeling as though you are regressing when feeling vulnerable. Therapy is a process that is often like taking three steps forward and one step back at times, but the overall momentum should be forward. Talking openly about this can help minimize stress about this process.
You are responsible for maintaining the confidentiality of others that participate in your counseling sessions, such as in family therapy sessions. In marital therapy, secrets between spouses works against successful outcome; in this regard, your counselor is not obliged to keep secrets of one spouse from the other spouse.
It is best to avoid abrupt terminations from counseling and to honestly discuss, preferably by video or phone, the reasons for your desire to end care or transfer to a different clinician. This method can maximize growth and health at these times.
Termination of Services
If you do not interact with me for a period of time (either through appointments or messaging back and forth), I cannot ethically continue a treatment relationship with you. Sometimes I am not the best fit to work with a client for a variety of reasons (personal fit, clinical experience, schedule availability, cost, etc.) Clients can decide to end services or change counselors at any time, however it is in your best interest to let me know you are doing so in advance . If you’d like to switch counselors within BetterHelp, you can do so by clicking on the icon in the top right corner of the “Counseling” page, and choosing “Change counselor” from the drop-down menu. Make sure you specify in the feedback to support what you are looking for that is different. If you have any trouble with this, please reach out to support at contact@betterhelp.com. Know that if you decide to take this action, you will lose all written correspondence with me at that time on your client dashboard.
To cancel your BetterHelp subscription, contact customer service via email (contact@betterhelp.com) or online at https://www.betterhelp.com/contact/ and ask them to cancel your account altogether. If you cancel your account and decide to return at a later date, BetterHelp will prompt you upon logging in about whether you would like to return to working with me, or find a different therapist. Please know that while I am happy to resume working with you at a later time, however, this is subject to my availability to see new or returning clients at that time.
If you do not cancel your account or request a new therapist, you will continue to show as an “inactive” client on my caseload whether or not you are logging in to the site or participating in services or not. Please note that your agreement for counseling services with me is considered no longer valid once you have not been in contact with me here for a period of 30 (thirty) calendar days. Exceptions to this are only made in discussion of clear dates and plans between us on a case-by-case basis. On the BetterHelp site/app, I will continue to send you this same message regularly until you either: 1. respond and resume contact with me, 2. change therapists, or 3. cancel your account. Thank you.
I AGREE TO THE CONDITIONS AND BOUNDARIES LISTED IN THIS CLIENT INFORMATION FORM. I ALSO AGREE TO NOTIFY MY THERAPIST OF ANY CHANGES PERTAINING TO THIS INFORMATION, AND UNDERSTAND THAT MY THERAPIST WILL DO THE SAME.
Signature:____________________________________________________
It takes courage to seek help. The first step is to reach out and address your concerns. Just know that once you seek help that you’re closer to creating change in your life. I’m ready when you are.
I look forward to working with you!
