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Informed Consent for asktheinternettherapist.com Email Session Online Services
(asktheinternettherapist.com disclosure page)

I certify that:

1. I am over 18 years of age.
2. I am not and have not been told that I need to be under the care of a physician for a major mental or emotional illness.
3. I am not receiving individual counseling or psychotherapy with another practitioner.
4. I am not at present feeling suicidal or homicidal.
5. I accept full responsibility for informing my counselor immediately if I believe I am becoming seriously depressed, or I am having thoughts of injuring myself or another person. I understand that he/she may contact emergency services in my are if he/she feels my state of mind poses a danger to myself or others.

I understand that:

1. The records and notes from my communications will be kept confidential except where my counselor is legally required to release them.
2. My personal information will be kept confidential. If I decide to use a different e-mail provider or chat nickname, I need to inform the counselor in advance.
3. My counselor will make every effort to return e-mails within 48 hours of receipt.
4. I am responsible for payment in advance for all services.
5. By clicking on this form I agree that the counselor I choose to work with can get supervision from Jef Gazley, LMFT. I further agree that if my counselor feels for any reason that my problems are not appropriate for online counseling I will seek outside face-to-face help. Also if my counselor feels I am a danger to self or others he/she has a right to contact my doctor if they know their contact information. I understand however that it is my responsibility to voluntarily seek out face-to-face counseling if my counselor advises or if I feel suicidal or homicidal.
6. I have read all the information listed here in the asktheinternettherapist.com disclosure page and by clicking the "I Accept" button below, I agree to all the above.