Teresa (Terry) Winston, MA, LPC

Direct: 651-274-1006

Clients Rights & Informed Consent for Treatment

Clients Rights: As a consumer of services, you have the right:
1. to be treated with respect and courtesy and in a culturally sensitive manner;
2. to be provided assistance with any communication barriers which make it difficult for you to
receive services;
3. to be free from discrimination while receiving services
4. to have access to your file according to therapy policy;
5. to terminate services at any time
6. to be free from exploitation for the benefit of staff;
7. to report complaints/grievances using the guidelines of Complaint Procedure memo;
8. to confidentiality as defined by policy and law. I maintain a strict policy on the confidentiality of
your records (in both written and computer file form). All information you share, or what we become
aware of through our work with you will remain confidential. There are some circumstances in which
this policy becomes void, and I am required by law to release information:
a. If I become aware through our work that you may be a danger to yourself or others,
b. If I become aware of or suspect child abuse or neglect;
c. If I become aware of or suspect abuse or neglect of a vulnerable adult;
d. If I am court ordered to testify or to submit records for court
In the above situations (a-d), I would be required to inform the appropriate authorities.
Informed Consent: Therapy is a voluntary relationship between people that works in part because of
clearly defined rights and responsibilities held by each person. You may withdraw from treatment at any
time without penalty and, I the therapist, reserve the right to terminate treatment if deemed ethically or
clinically necessary.
Therapy does not offer any guarantees. As we build a therapeutic relationship, I will offer my services to
the best of my ability and I will expect that you put as much effort into the process as you expect to get out
of it.
If at any time you become dissatisfied with what is happening in therapy, I hope that you will talk about it
with me so that I can respond to your concerns. I will take such criticism seriously, and with care and
respect.
When the client is a minor, both parents (regardless of marital status or custody arrangements) have the
right to be informed about their childs treatment, and I will typically encourage family therapy when I feel
it is necessary. However, the confidences shared in individual sessions by a child or adolescent will be
respected so that an effective therapeutic relationship can be established.
With regards to couple, family or group therapy, each of the clients present must, in writing, waive
confidentiality before any records or information can be released. As well, if you and you partner or family
member decide to have some individual sessions as a part of the couple or family therapy, what you say in
those individual sessions will be considered to be a part of the couple or family therapy and can and
probably will be discussed in our joint sessions. I am not a secret keeper and will encourage you and work
with you to share your secrets with your partner or family member.
Records and Record Keeping: A brief written summary of each session will be recorded for my record
keeping purposes (i.e., who, when, and what was discussed). This is called a progress note. If records
are requested by the client, a summary of the records will be submitted to the requesting party. The
physical record is the property of my counseling office and I will maintain your records in a locked, secure

Clients Rights/Informed Consent for Treatment

location for a minimum of 7 years, according to Minnesota Law. If someone else outside of court mandated
laws, request your records, a signed consent form is required from you before releasing records.
Training, Credentials, and Ethical Regulations:
a. I am a graduate of Adler Graduate School of Psychology and a Licensed Professional Counselor.
My approach to therapy is to meet my clients where they are by guiding, encouraging, and motivating
growth and change.
b. I have a background in early child development. I have worked in this field for 14 years. I am an expert
and will be able to help assist with parent coaching needs as well.
c. I will use a variety of techniques in therapy, trying to find what will work best for you. I may suggest
that you consult with a physical health care provider, another therapist, or a participate in a therapy or
support group as part of your work with me. I will provide appropriate referrals as necessary. You have
the right to refuse anything that I suggest without being penalized in any way.
d. In addition to the laws and rules governing my clinical behavior, I am also ethically bound to the
AAMFT Code of Ethics (American Association of Marriage & Family Therapists). You may retain a
copy of the Code of Ethics by contacting the AAMFT through their website at www.aamft.org.
Legally and ethically, I do not engage in social or sexual relationships with clients or former clients.
Collaboration with other professionals: There may be times when I discuss our session material with
other collaborating professionals. For additional consultation, there are times I may speak with colleagues
to achieve the optimal treatment plans for my clients. In any case such as this, it is my utmost desire to
respect your confidentiality. Please know that at these times that no identifying characteristics of a personal
nature will be mentioned (they will not know your name or any other personal information that could
identify you).
Emergency Contact After Hours: Limited resources prevent me from providing crisis intervention or
intensive counseling. If you have a crisis after office hours, please contact your physician; call the crisis
hotline within your county, dial 911, or go to the nearest hospital emergency room.
Out of the Office: If I am going; to be away from the office, I will tell you well in advance. If I have an
emergency, I will contact you immediately to reschedule our session. If I have difficulty with contact for
whatever reason, I will leave a message with the client via voicemail. If you have an emergency in between
session or while I am out of town, you are encouraged to call 911.
Your Responsibilities as a Therapy Client: You are responsible for being available for your sessions on
time. If you are late, please contact me immediately at 651-274-1006. Please be warned that we will
continue to stay on our scheduled time arrangement. Meaning you will not get the full 50 minutes of
session time that was originally scheduled. If you need to cancel an appointment, please do so within a 24
hour period of our scheduled meeting time. Our session will be 45 minutes each session. My fee for
therapy is $40.00 Fees are subject to change.
* $75 Group
* $90 Individual
* $95 Couple
* $100 Family
* Sliding fee
Parent Work Shops: TBD
Parent Coaching: TBD
Assessments & Diagnosis: $250 per assessment/diagnosis
Premarital Inventory: TBD

Sliding fees are available to those who are experiencing financial hardship. Sliding fees are discussed in
detail during the initial call or session.

Clients Rights/Informed Consent for Treatment

All fees must be paid in advance before service is rendered. I will occasionally offer sliding fees to
clients who may be experiencing financial hardship. I accept cash, checks, or money orders as a form of
payment. There will be an additional $38 dollar charge for returned checks.

Consent for Treatment of Minors (if applicable):

I/We, ______________________________________, the parent(s) of ___________________________,
gives Teresa Winston, MA, LPC permission to provide psychotherapy services to my/our child. I recognize
that I have a duty to be reasonably available to provide consent to changes in my childs treatment and to
participate in treatment as deemed necessary and appropriate.
**In the event of separation or divorce, it is understood that BOTH parents, regardless of custody, must
sign this form BEFORE services can be rendered to a minor. (A notarized original may be sent by mail).
As well, documentation of the custody arrangement must be provided and a copy will be kept in the file
______________________________________________________________________________________
Client Consent to Psychotherapy Services:
I HAVE READ THIS STATEMENT, HAD SUFFICIENT TIME TO BE SURE THAT I CONSIDERED IT
CAREFULLY, ASKED ANY QUESTIONS THAT I NEEDED TO, AND I UNDERSTAND THE
INFORMATION OUTLINED ABOVE. I HAVE REQUESTED A COPY, IF I WISH, OF THIS AND
ANY OTHER FORM I HAVE SIGNED. I CONSENT TO HAVE THE NECESSARY INFORMATION
RELEASED IN ORDER FOR ME TO FILE AN INSURANCE CLAIM. I UNDERSTAND MY RIGHTS
AND RESPONSIBILITIES AS A CLIENT, AND MY THERAPISTS RESPONSIBILITIES TO ME.
WITH THIS UNDERSTANDING, I AGREE TO UNDERTAKE THERAPY WITH TERESA (TERRY) L.
WINSTON, MA, LPC.
Client Signature: ____________________________________________Date:_____________________
Client Signature: _____________________________________________Date: ____________________
Parent(s) Signature (or legal custodian) if treatment is for a minor child:
___________________________________________________________Date: _____________________
___________________________________________________________Date: _____________________
Please initial:
___________ I/We acknowledge that I have received a copy of this form
___________ I/We acknowledge that I have refused a copy of this form