1. You agree that you are at least 18 years old

2. You understand that your counselor is a Licensed Professional Clinical Counselor by the State of Ohio

3. You agree that you have read the separate section on Confidentiality and you agree with the terms set out in that section

4. You agree to supply your true full name, address, phone number, and all other requested information on the Client Questionnaire.

5. You agree that all of the information you have provided in the Client Questionnaire is accurate, and that if any of this information is inaccurate, this will be a major limitation on the counselor's ability to help you.

6. You understand that CCS Training Services cannot guarantee a positive counseling outcome, even though, in agreeing to work with you, your counselor is hopeful that your work together will be of help to you

7. You understand that telephone counseling is a new counseling process and research into its effectiveness is just beginning. And, as with other counseling processes your commitment and feedback are valuable to your success. 

8. You agree that telephone counseling is not equally safe and effective for all individuals. Thus, your counselor reserves the right to choose whether or not to work with you by telephone and will work with you only if you are assessed to be a suitable client. If, during your work together, your counselor discovers that you are not a client that can benefit from telephone counseling, your counselor will discuss this with you and suggest that you seek face-to-face counseling help through other mental health professionals in your local area such as a psychiatrist, psychologist, social worker or another counselor.

9. You understand that telephone counseling and face-to-face psychotherapy are not the same. Therefore, your counselor cannot make any formal diagnoses for telephone counseling nor carry out traditional psychotherapy online. In addition, if at any point in our work together your counselor believes that it would be in your best interests to see a counselor face-to-face, your counselor will explain this to you and ask that you locate a counselor in your local area to work with.

10. You agree and understand that the effectiveness of telephone counseling depends on the investment of time and energy you are willing to make

11. You agree that your counselor cannot be held responsible for providing services to you in the event of a potentially life-threatening crisis or emergency situation and that you may need to seek local supports if such a situation arises.

12. You understand that CCS Training Services cannot be held responsible for unforeseen problems that may occur in telephone services due to malfunction and/or loss of electricity or connection.

13. The CCS Training Services’ office phone number is posted on the CCS website and if you don't hear from your counselor when you expect to, call the CCS offices immediately.

14. Routine Counseling Confidentiality: You understand and agree that as a counselor, CCS protects the confidentiality of the communications and contacts with all of CCS clients, including telephone clients. Your written consent is always necessary for your CCS counselor to release information about your work to others except in the following situations:

a.  If your counselor learns while working with you that a child, elderly person, or disabled person is being abused, CCS is legally required to notify appropriate protective services.

b.  If CCS is required by a court order or legal subpoena to release information about your counseling.

c.  If you tell your counselor that you are considering: 1). committing suicide; 2) committing serious self-injurious behavior; or 3). considering violence towards another person, CCS required to notify the appropriate authorities.

d. You understand that when receiving telephone counseling, it is impossible to guarantee 100% confidentiality protection. However, CCS will do everything possible to protect against any intrusions on the organization’s end of the connection. While there are always risks to your confidentiality in any setting, these risks are extremely small assuming common sense is used and appropriate precautions are taken.

15. The goal of your telephone counseling is to help you. Therefore, if you or your counselor feels, at any time, that working together is not helpful enough to you; either you or CCS is free to terminate your relationship at any time.

16. There are no other explicit or implicit commitments in our relationship.
     

I understand and agree to each of the 16 terms and conditions stated above. 

Yes
No

Please provide your Full Name in the box below and then Submit this form. 

Thank you.