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Informed Consent for Love Counseling Center
Welcome to Love Counseling Center!
We are honored to support you on your journey toward emotional well-being, personal growth, and relational healing. This form outlines essential information about your rights, the counseling process, fees, and our policies.
1. PURPOSE OF COUNSELING
The goal of counseling is to provide a safe and supportive environment for individuals, couples, and families to address emotional, relational, and mental health challenges. Our licensed counselors help clients: • Improve communication • Resolve conflicts • Foster intimacy • Strengthen personal and family well-being
2. CONFIDENTIALITY
Your privacy is a priority. All sessions are confidential, except in these legal and ethical exceptions: • Threats to harm yourself or others • Suspected abuse of a child or vulnerable adult • Court orders requiring disclosure
3. OUR APPROACH
We use a client-centered, evidence-based approach tailored to your needs. Sessions may include goal setting, skill building, emotional processing, and practical strategies for achieving lasting change.
4. TYPES OF COUNSELING OFFERED
• Individual Therapy: Personal support for emotional and relational concerns. • Couples Therapy: Joint sessions to improve communication, resolve issues, and deepen intimacy. • Family Therapy: Guided sessions to strengthen family dynamics and address conflicts.
5. CLIENT RESPONSIBILITIES
Successful counseling requires: ✔ Honest participation ✔ Openness to growth ✔ Commitment to the process ✔ Communication with your therapist about concerns
6. COUNSELING FEES
Standard Fees (Online or In-Person): • Individual 45-min: $100–$150 • Individual 60-min: $125–$200 • Couples 50–60 min: $150–$300 • Extended Couples: $200–$300+ Sliding Scale Available: We offer income-based fees for those in financial need. During your intake, we will assess your situation and determine an adjusted rate that suits your needs. Package Deals (Save More When You Commit): • Starter Package: 3 Individual Sessions – $270 (Save 10%) • Couples Connection: 5 Couples Sessions – $550 (Save 20%) • Total Wellness: 10 Sessions – $950 (Save 25%) 💳 Payment methods: Credit cards, electronic transfers 📄 We provide superbills for insurance reimbursement (based on your coverage).
7. CANCELLATION POLICY
Please give at least 24 hours’ notice for cancellations. Missed appointments or late cancellations will incur a fee equal to the session cost.
8. CONSENT
Please sign below to confirm that you understand and agree with the terms outlined above. If you have any questions, please don't hesitate to speak with your counselor at any time.
Client Signature
Client Signature
❌
Client Signature Date
Parent/Guardian Signature
Signature of Guardian
❌
Guardian Signature Date
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