Informed Consent Agreement for Psychotherapy

Thoughtful Measures LLC

Latoya Lyle-Kirlew, LMFT

200 North Village Ave, Suite 101, Rockville Centre, NY, 11725

Thoughtful.measures@gmail.com

Introduction

Welcome to my practice, Thoughtful Measures. I am committed to providing a safe and supportive space for your personal growth. This document outlines important information about our work together, including policies, confidentiality, and your rights as a client. Please read it carefully and ask any questions before signing.

Therapeutic Process & Expectations

Therapy is a personal journey that varies from individual to individual. It is a collaborative process that may involve discussing difficult emotions, personal history and challenges, and relationship concerns. While therapy can be beneficial, there are no guaranteed outcomes. Progress depends on various factors, including your commitment and willingness to engage in the process.

Confidentiality & Its Limits

Your privacy is a top priority. However, there are exceptions to confidentiality where I may be legally required to disclose information:

1.	If there is suspicion of child abuse, elder abuse, or dependent adult abuse.

2.	If you express intent to harm yourself or others.

3.	If I am subpoenaed by a court of law.

4.	If you authorize the release of information in writing.

Fees & Payment

Sessions are typically 45 minutes and occur on a weekly or biweekly basis, unless we agree otherwise. My session fee is $120 per session. Payment is due at the time of service unless other arrangements have been made.

Accepted payment methods include cash, credit card, checks, insurance, Zelle, Venmo.

If you are using insurance, you are responsible for any copays, deductibles, or non-covered services.

Cancellation & No-Show Policy

Cancellations must be made at least 12 hours in advance. Late cancellations and no-shows will be charged $25, unless waived at my discretion.

Communication & Emergencies

I can be reached at (203) 559-1885 for scheduling and non-urgent matters. I do not provide 24/7 crisis services. In case of an emergency, call 911 or go to the nearest emergency room. You can also contact the National Suicide Prevention Lifeline at 988.

Telehealth Services (if applicable)

If you choose to engage in teletherapy, please ensure you are in a private, distraction-free environment. Telehealth sessions are conducted via Simple Practice, a HIPPA compliant platform. While I take measures to protect your confidentiality, there are inherent risks with electronic communication, including potential privacy breaches.

Professional Growth

I am a Licensed Marriage and Family Therapist (LMFT) currently enrolled in a PhD program and completing my internship. In addition to my clinical training, I am actively expanding my expertise by participating in advanced therapeutic training programs. I am enrolled in the Gottman Therapy Level 1 and Level 2 courses, as well as the Emotionally Focused Therapy (EFT) Step-by-Step training. My approach integrates these evidence-based modalities to provide you with effective, research-supported care.

Additionally, as part of my commitment to ongoing professional growth and adherence to ethical standards, I participate in clinical supervision. This means that I may discuss aspects of your case with my supervisor or consultation group while omitting identifying details to protect your privacy. Supervision enhances the quality of care I provide and ensures that you receive the most effective treatment possible.

Client Rights

You have the right to ask questions about your therapy, decline certain interventions, or seek a second opinion. You may discontinue therapy at any time, though I encourage discussing this decision so we can review your progress and options.

Consent & Agreement

By signing below, you acknowledge that you have read, understood, and agreed to the terms outlined in this informed consent. You consent to engage in therapy and understand you may withdraw at any time.

Client Name (Printed): ________________________

Client Signature: ________________________ Date: ______________

Therapist Name: ________________________

Therapist Signature: ________________________ Date: ______________