Grace & Hope in Loss, LLC

Georgina Manahan, M.A.

814-571-0258

grace.hope.counseling@gmail.com

                                                                                                                                           INFORMED CONSENT

I understand that counseling begins with an evaluation of events, past and present. While Georgina Manahan is deciding whether she is the appropriate counselor for me, I will decide whether I wish to begin a counseling relationship with her. I understand that because of the commitment of time and money, plus the potential impact on me and others, it is important to make an informed choice for Christian counseling.

I agree to share responsibility with Georgina Manahan for the counseling process, including goal setting and termination. By entering into counseling, I accept that I understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach counseling goals. I understand that the changes I make will have an impact on me and others around me. I accept that such changes can have both positive and/or negative effects and agree to clarify and evaluate potential effects of changes before undertaking them.  I agree to be open and honest with Georgina Manahan and take an active role in the direction of my counseling.

I understand that information discussed in counseling is confidential and privileged.  Under state law, Georgina Manahan is required to break confidentiality if there is a threat of harm to either self or others.  I understand that Georgina Manahan will strive to otherwise maintain confidentiality and will receive my consent prior to releasing information under other circumstances. I understand that information discussed in counseling is confidential and for therapeutic purposes and is not intended for use in any legal proceedings.

I agree to pay for all services provided by Georgina Manahan.  I further agree to provide Georgina Manahan at least 6 hours advance notice if I cannot keep a scheduled appointment.   I understand that Georgina Manahan has the option to charge one-half of the normal session fee if I fail to give adequate notice. 

By signing below, I agree to accept the counseling services from Georgina Manahan, dba Grace & Hope in Loss, LLC and accept full responsibility for payment for such services.

Client_______________________________ Date______________________

Counselor _____________________________ Date_____________________