Informed Consent Agreement
By clicking on the link at the bottom of this page I acknowledge that I have read, understand and agree to the following stipulations, Privacy Policy and Terms and Conditions that must govern, while engaged in the psychotherapeutic relationship between myself and Milton Anthony.
1. Should I reveal, or if it is reported to this therapist, while engaged with this psychotherapeutic relationship, that I have conspired to, or committed abuse and/or neglect to any child, or to any senior citizen, or if suspected by or evidenced by this therapist, this will be reported to proper authorities which may include the Department of Human Resources and/or appropriate law enforcement personnel. The undersigned is aware this reporting is required by law in the State of Alabama and by the Code of Ethics which governs Licensed Professional Counselors in the State of Alabama.”
2. While engaged in this psychotherapeutic relationship, should I reveal that I am thinking about, or that I have committed homicide to another human being, or that I am thinking about committing suicide, or if suspected by or evidenced by this therapist, this also will be reported to proper authorities and/or appropriate law enforcement personnel.
3. I am aware that this therapist, Milton Anthony, is a Licensed Professional Counselor, and is ethically governed by the Alabama Board of Examiners in Counseling. The undersigned also understands that during this counseling process, my case maybe discussed with another professional counselor, such as Deborah Nichols, as well as, documentation of sessions maybe reviewed by the same said professional. Should I desire to have my case discussed with other professionals or family members or have information released to these other professionals or family members, I am aware I must sign the appropriate release of information document.
4. Although as a professional, Milton Anthony will attempt to maintain the client engaged in the therapeutic process’s confidentiality, the client is aware that a Court of Law may subpoena his/her information and Milton Anthony will be required by the Court to release said records.”
5. Other than stipulations 1 through 4, Milton Anthony will hold and keep this and all other interviews between myself and Milton Anthony, completely and totally confidential.
6. I agree to acknowledge, with an open mind, and to attempt performing tasks, assigned to me by Milton Anthony, as part of this treatment process.
7. If I wish to make a complaint about or against Milton Anthony, during any part/time of this therapeutic relationship, I am to notify his governing board, at the following e-mail address, and/or telephone number: florence.hemphill@abec.gov (205) 458-8716
By clicking on the Submit Button, "I Agree," you have read and agree to the Informed Consent Agreement and Privacy Policy.