Informed Consent and Overview of Important Policies & Procedures

Instructions and Purpose of This Form

Thank you for choosing Breakthrough Therapy Solutions (BTS). This form outlines important information regarding your rights, responsibilities, and some key policies of BTS to help you make an informed decision about entering therapy. The information provided complies with relevant local, state, and federal laws, as well as the ethical guidelines governing Licensed Professional Counselors in New Jersey.

Please read each section of this form carefully and complete all required fields, including signatures.

This form may be updated periodically, requiring review and signature.

CONTENTS

1. Overview of Psychotherapy
2. Confidentiality & Limitations
3. Communication & Technology Policy
4. Crisis & Emergency Policy
5. Access to Records Policy
6. Third-Party Communication Policy
7. Financial Arrangement & Payment Policy
8. Cancellation & Attendance Policy
9. Minor Clients Policy
10. Couples & Family Therapy Policy
11. Termination Policy
12. Client Rights & Responsibilities
13. Additional Documents & Policies
14. Consent to Treatment
15. Next Steps

1. OVERVIEW OF PSYCHOTHERAPY

This overview is intended to help you make an informed decision about participating in therapy. Please feel free to ask questions or express any concerns at any time during the therapeutic process.

Risks and Benefits of Psychotherapy

Psychotherapy, also referred to as mental health services, counseling or therapy, often involves discussing emotional, psychological, and interpersonal issues. While it can lead to significant improvements, there are no guaranteed outcomes. Therapy may involve exploring difficult topics, which can evoke strong and uncomfortable emotions. The process is collaborative and tailored to your needs. Progress varies for each individual, and success depends on factors such as personal commitment, the therapeutic relationship, and the nature of the concerns being addressed. Therapy is not a substitute for medical care or legal advice.

Approach to Therapy at BTS

At Breakthrough Therapy Solutions (BTS), our approach to therapy is grounded in evidence-based practices that are tailored to meet the unique needs of each client. We believe in creating a collaborative and supportive environment where clients feel empowered to explore their challenges and work toward meaningful change. Our clinicians draw from a variety of proven therapeutic modalities, ensuring that treatment is flexible, personalized, and responsive to the individual’s goals and experiences.

Who Provides Psychotherapy Services at BTS?

All clinicians providing services at Breakthrough Therapy Solutions (BTS) are licensed by the State of New Jersey and authorized to deliver mental health services. In New Jersey, the minimum educational requirement to provide mental health services is a Master’s degree.

Clinicians with a provisional license work under the supervision of a Qualified Supervisor until they meet the requirements for full, independent licensure. These requirements are outlined in N.J.A.C. 13:34-23.1.

Clients are informed of their assigned clinician’s details prior to the start of services. If the assigned clinician is under supervision, clients will also receive the supervisor’s credentials and contact information.

2. CONFIDENTIALITY

• Clients have the right to confidentiality regarding therapy sessions and records. Client information will not be shared without client (or guardian) consent, except in cases where disclosure is required by law.
• BTS may share information with third-parties if client signs a Release of Information form, granting permission for such disclosure. Therapist and BTS reserve the right to deny sharing information, even if permission is granted by client.
• As per HIPAA requirements, a Notice of Privacy Practices is provided to all clients prior to starting therapy services with BTS. This can also be found on our website, www.btstherapy.com. All clients have the right to request a copy of this be provided to them at any time.
• At BTS, we prioritize the confidentiality and security of your personal information. We utilize HIPAA-compliant vendors and platforms for essential services, including electronic health records (EHR), billing and clearinghouse functions, accounting, and IT support. These trusted partners are carefully selected to ensure that all client data is handled in accordance with federal privacy regulations, maintaining the highest standards of protection and confidentiality.

LIMITATIONS

• There are situations where BTS and/or Clinician is required to share information and consent and permission is not required. This includes situations involving imminent risk of harm to client or others, suspected abuse or neglect, compliance with court orders or other applicable situations.
• As mental health professionals, we are mandated reporters, legally obligated to report any suspected abuse, neglect, or harm to client or others to the appropriate authorities to ensure safety and compliance with applicable laws. This responsibility also extends to information received from outside sources and is not limited to information shared only by the client. In instances where reporting is necessary, it will be done promptly and does not require additional client consent or the consent of any other party.

3. COMMUNICATION & TECHNOLOGY POLICY

COMMUNICATION METHODS AND NOTIFICATION OF RISKS

This section outlines the policies and procedures for communication outside of scheduled sessions. This policy is designed to ensure the confidentiality, integrity, and security of Protected Health Information (PHI) in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

• To maintain confidentiality and protect your privacy, all communication outside of scheduled sessions should be limited to administrative matters only (e.g., scheduling, billing, payment). Clinical or therapeutic discussions must take place during sessions to protect privacy and uphold ethical standards of care. This policy helps preserve the integrity of the therapeutic process and minimizes the risk of privacy breaches.
• We understand that some clients prefer to communicate with therapist ahead of their session for various reasons. There are alternative and secured options available if this is something that is important to you. Your therapist or Nicole Monroe, Clinical Director can provide you with more information upon request.
• Whenever possible, communication will occur through HIPAA-compliant and secured methods. While we take every precaution to ensure confidentiality, electronic communication (email, text, video) carries risks, including interception by third parties, accidental disclosures, or technical breaches.
• Clients are responsible for safeguarding the privacy of their communications. Please refrain from using public or shared devices to discuss sensitive information.
• This document serves as notice of the potential risks of using unsecured communication methods. Any client who initiates an email or text implies consent to that method of communication unless they explicitly state otherwise in writing. Therapist is only permitted to respond to communications regarding NON-CLINICAL content, such as scheduling, billing, logistical information, etc.
• All communications between clients, clinicians, and BTS — including emails, texts, and phone calls — will be documented in the client’s medical chart to ensure accurate record-keeping and continuity of care.
• Please see section #4, below, for details regarding communicating during a crisis or emergency.

SOCIAL MEDIA POLICY

• To protect client confidentiality and maintain professional boundaries, BTS clinicians do not engage in communication with clients through social media platforms. This includes, but is not limited to, messaging, commenting, or connecting through personal or professional accounts.
• Clients are encouraged to use secure methods, such as phone or email, for all communications regarding services. Any inquiries or concerns received via social media will not be addressed to ensure privacy and ethical standards are upheld.

TECHNOLOGY IN PSYCHOTHERAPY: METHODS AND NOTIFICATION OF RISKS & LIMITATIONS

• Telehealth sessions are available and conducted through HIPAA-compliant platforms.
• Telehealth services are available only to clients physically located in states where the therapist is licensed.
• Clients are responsible to ensure they are located in a private, quiet location during teleheealth sessions to maintain confidentiality.
• Telehealth services are reserved for clients for whom it is clinically appropriate and safe.
• Recording of sessions by either party is not permitted without prior written consent from all parties. This protects the privacy and integrity of the therapeutic relationship.
• All clients will be provided Informed Consent for Telehealth Services prior to starting with BTS.

4. CRISIS & EMERGENCY POLICY

DEFINITION OF EMERGENCY OR CRISIS

• Client expresses intent to harm self or others.
• There is imminent concern regarding safety and well-being of client or others.
• Client shows severe signs of emotional distress.

PROCEDURE FOR HANDLING CRISIS OR EMERGENCY SITUATIONS

• If crisis or emergency is observed by Clinician during a session, the counselor and/or supervisor will assess situation and determine appropriate intervention. This may include contacting an emergency contact person, with permission of client through a Release of Information form or verbal permission, in accordance with applicable laws and regulations; or calling 911 or other local emergency services for assistance.
• If crisis or emergency situation occurs outside of session, clients are instructed to call 911, local emergency services, crisis hotline or visit the nearest emergency room for assistance.
• BTS staff are not available 24/7 and are unable to immediately handle crisis or emergency situations outside of sessions. It is imperative that clients call 911 or access other local emergency services for assistance during a crisis or emergency.
• Clients should notify BTS as soon as possible following a crisis or emergency in order to ensure proper clinical care can be provided.

5. ACCESS TO RECORDS POLICY

CLIENT REQUEST FOR ACCESS TO RECORDS

• In accordance with the Notice of Privacy Practices, clients are entitled to access their clinical records. BTS will adhere to all relevant ethical standards, laws, and regulations when releasing records or information to the Client or an authorized third party (Requesting Party).
• All requests must be reviewed and approved by Clinical Director/Owner of BTS, Nicole Monroe. BTS reserves the right to decline requests that are not deemed clinically appropriate or are not required to be released in accordance with applicable laws and regulations.
• Upon receiving a formal, written request for the release of records, BTS and/or the Clinician will have thirty (30) calendar days from the confirmed receipt of the request to respond. BTS and/or Clinician will inform Client of any required documentation needed to process the request.
• If the required documentation is received, the Client and/or Requesting Party will receive a Payment Agreement detailing the anticipated estimated cost of the request and the Initial Payment due. Preparation to fulfill request will not begin until Initial Payment is received. Upon completion of the request, the Client and/or Requesting Party will be notified and a final invoice will be provided to Client and/or Requesting Party. The records will not be sent until the final invoice is paid in full. Upon receipt of final payment, BTS will release the prepared records request within seven (7) business days.

The Client understands that, under 45 CFR 164.524(c), BTS and/or the Clinician may charge a reasonable fee for record requests. This fee may include costs related to:

• Time spent preparing records and documents
• Supplies and materials used in document preparation
• Postage or shipping
• Any additional expenses incurred in fulfilling the request

6. THIRD-PARTY COMMUNICATION POLICY

GENERAL POLICY INFORMATION

• The Client agrees that any third-party communications (excluding insurance or billing entities contracted with BTS) must be approved by Nicole Monroe, Clinical Director and Owner of BTS, regardless of the Clinician assigned to the Client.
• BTS and/or the Clinician reserve the right to decline third-party communication requests, provided this refusal complies with applicable ethical codes, and local, state, and federal laws.

LITIGATION/COURT RELATED REQUESTS

• BTS does NOT participate in litigation-related matters unless mandated by a court order. If such participation is required, the Client agrees to cover all associated costs. This applies even if the Client is not the requesting party. The Client may seek reimbursement from the requesting party but understands that BTS will not facilitate this process beyond issuing invoices.
• BTS and all staff do NOT provide expert witness services, opinions or recommendations outside the scope of treatment with a client and only if required by a Court Order.
• BTS and all staff do NOT participate in custody or parenting evaluations, assessments, reunification or other related matters. Clients should seek out specifically trained and court-approved providers for such services.
• If court participation or related services are required, a Consent for Legal Involvement Release form must be signed by client prior to proceeding. This will outline required documentation as well as the terms and conditions of BTS involvement.
• BTS will provide client with an invoice outlining the anticipated charges and initial payment due. Payment is due immediately upon receipt. If the Client has an active credit/debit card on file with BTS, the card may be charged unless alternative payment arrangements are made at the time of invoicing.
• BTS reserves the right to request additional payments throughout the process if anticipated charges are expected to exceed the initial estimate by more than $250. Additional estimated invoices will be provided to client detailing anticipated charges.
• Upon completion of the Clinician’s involvement in such matters, a final invoice will be issued to the Client, reflecting all charges incurred beyond the initial estimate. If monies are owed to client as a result of overpayment, BTS will issue refund to client within five (5). business days.

7. FINANCIAL ARRANGEMENT & PAYMENT POLICY

As part of our commitment to transparency and clarity, the following outlines the financial policies and payment arrangements for counseling services at BTS:

Payment Policy:

• Payment is due at time of service for copay, deductible, coinsurance or self-pay costs as well as all other services, cancellations and other fees.
• Outstanding balances must be paid prior to scheduling future sessions, unless alternative payment arrangements are agreed to in writing.
• Outstanding balances beyond 30 days may incur late payment penalties of 5% of outstanding balance total. This is calculated monthly.
• Outstanding balances may be sent to collections after 90 days.
• Accepted payment methods: credit or debit card, Venmo, PayPal, Zelle, HSA/HRA/FSA cards, cash or check.
• Self-pay clients will be provided with a separate Financial Agreement outlining details and fees. A Good Faith Estimate will be provided in accordance with the No Surprises Act.
• Sliding Scale payment arrangements, promotions, discounts, etc are available at the discretion of BTS. Clients experiencing financial hardship should notify Clinician and/or BTS to discuss financial options.
• Fees are subject to change. In the event of a fee change, BTS will provide client with at least 30 calendar days' notice and a new Financial Agreement will be signed by client. All such changes will be in accordance with local, state and federal laws and guidelines.
• BTS requires that a valid credit/debit card be kept on file for all clients, unless alternative arrangements are made in writing.

Insurance and Third-Party Payer Policy:

• BTS accepts some insurance or third-party payment plans and will attempt to set up direct billing for those plans as a courtesy. However, this is not guaranteed for all plans.
• Clients are responsible for knowing their insurance or other benefits. Although BTS may offer to check insurance benefits as a courtesy, BTS is not responsible for verifying coverage and cannot guarantee the accuracy of any such verification.
• Clients are ultimately responsible for the full payment of services, regardless of insurance or third-party coverage. If insurance company or third-party payer denies payment, partially denies payment or retroactively recoups payment (sometimes called a CLAWBACK) already made to BTS, client will be responsible for the charges. Client may negotiate with insurance company or 3rd party payer on their own but BTS will not engage in such negotiations between client and payer.
• Clients must inform BTS of any changes to their insurance or benefits immediately (e.g., lapse in coverage, job changes, new insurance, additional insurance etc.).
• Clients are responsible for copays, deductibles, and any unpaid fees at the time of service and may not carry a balance, unless a separate Financial Agreement has been agreed to by client and BTS.
• Clients who utilize insurance or third-party payment arrangements understand and agree that fees are determined by the current contract between BTS and the third-party payer. Contracted rates are subject to change at the discretion of the payer. BTS will inform clients of any changes as soon as this information is received. However, all fees are charged in accordance with the contracted rate effective at the time services are provided. Clients remain responsible for any portion of fees not covered by their insurance or third-party payer. Advance notice of contracted rate changes is NOT required in such cases.

Additional Costs:

• In addition to session fees, clients may incur charges for services outside of standard therapy sessions. These may include, but are not limited to, fees for letter writing, documentation requests, treatment summaries, court appearances, consultations with other providers, and extensive phone calls (over 15 minutes). Charges for these services will be discussed in advance, and rates will be provided upon request. Please note that insurance typically does not cover these additional services, and clients are responsible for full payment.

8. CANCELLATIONS & ATTENDANCE POLICY

Our Cancellation & Attendance Policy was created with flexibility in mind. Please review the policy carefully to familiarize yourself with the policy and procedure.

24-Hour Notice Requirement:

• Clients are required to provide at least 24 hours' notice to cancel or reschedule an appointment.

Late Cancellations:

• The first late cancellation (less than 24 hours’ notice) will be waived as a courtesy.
• After the first occurrence, any cancellation within the 24-hour window will incur a $50 late cancellation fee.
• This fee is not covered by insurance or third-party payers and must be paid at the time fee is incurred (same day as scheduled session).

No-Show Policy:

• If a client does not attend a scheduled appointment and provides no prior notice, the full session fee will be charged. The full session fee is determined by each client's Financial Agreement or insurance plan's current contracted fee with BTS at the time of scheduled session.
• No-shows are not eligible for the one-time waived fee.

Repeated Late Cancellations or No-Shows:

• After three (3) late cancellations or no-shows, the client may:
  • Have a discussion with Clinician and/or BTS Supervisor to address attendance concerns and explore any barriers to consistent participation in therapy. BTS and clinicians will collaborate with the client to find reasonable solutions and make appropriate arrangements.
  • Risk losing ongoing advanced scheduling privileges.
  • Be required to pay a deposit for future sessions in advance to secure appointment times.

Therapist Cancellations:

• There may be occasions when your clinician needs to cancel or reschedule an appointment. Our policy is to provide as much notice as possible and to ensure that our approach aligns fairly with the established cancellation and attendance policy.
• In the rare event that Clinician must cancel within 24 hours, the Client will receive an additional late cancellation waiver that can be used for a future late cancellation to provide some flexibility.
• Clinician will also work with client to reschedule session to a date/time that is convenient for both.

Emergency Exceptions:

• Exceptions to this policy may be made in cases of emergencies or unavoidable circumstances. Please communicate as soon as possible if such a situation arises.
• Exceptions will be handled by BTS Supervisor, Nicole Monroe, on a case-by-case basis.

PROCEDURE TO CANCEL/RESCHEDULE

1. ON-TIME CANCELLATION/RESCHEDULE REQUEST: To cancel or reschedule an appointment MORE than 24-hours in advance, please use one of the following methods:

• Email, text, or call your assigned clinician (contact information provided at intake).
• Email, text, or call BTS at: Nicole.monroe@btstherapy.com or nmonroecounseling@gmail.com, 848-373-8444
• Send a message through the client portal (instructions provided at intake).

Important: It is the client’s responsibility to ensure that the cancellation or rescheduling request has been received and acknowledged by the clinician or BTS for all cancellation requests.

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2. LATE CANCELLATION/RESCHEDULE REQUEST: To cancel or reschedule within 24-hours of scheduled appointment, please follow the procedure below, in the order listed:

• Text or call BTS phone at 848-373-8444. If you do not receive a response within 30 minutes, you may try again and/or:
• Text or call Clinician. If you do not receive a response within 30 minutes, you may try again and/or:
• Email BTS main email at Nicole.monroe@btstherapy.com (secured) or nmonroecounseling@gmail.com (unsecured).
• You may also email Clinician. In the email, please indicate that you attempted to text/call BTS and/or Clinician and did not receive a response. Include necessary details for the cancellation.

**All BTS staff strive to return messages promptly; however, there may be times when this is not possible. To ensure clarity and consistency, the outlined policy provides clients with a clear procedure for canceling or rescheduling appointments, including those within the 24-hour window.

9. MINOR CLIENT POLICY (only applicable if client is a minor)

When providing therapy services to minors, it is essential to create a safe, supportive, and collaborative environment. This section outlines the roles, responsibilities, and policies regarding the treatment of minor clients and are in accordance with all applicable local, state and federal laws as well as applicable regulations and ethical guidelines for mental health professionals in New Jersey.

Consent for Treatment:

• When applicable, a parent or legal guardian must provide written consent for therapy services before treatment can begin. Written consent can be in the form of signing all consent and intake forms. A parent or legal guardian's signature on these forms constitutes consent for the minor to receive treatment and attend sessions.
• If parent or legal guardian wishes to revoke consent, a written request must be provided to Clinician and/or BTS. Parent/legal guardian is responsible to obtain written acknowledgment of receipt of such request from Clinician and/or BTS.
• For minors aged 14 and older, both the minor and the parent or legal guardian are required to sign the consent forms, in accordance with N.J.A.C. 13:34-18.6. If minor is under 14 years old, only parent or legal guardian signature is required.
• If legal custody is shared or in dispute, documentation verifying the authority to consent for the minor may be required. BTS and/or the clinician reserve the right to terminate treatment and refer the minor client to a provider with the appropriate skills and experience to address family dynamics involving custody disputes or parenting conflicts that may be considered beyond the scope of practice of Clinician at BTS.

Confidentiality and Communication:

• Therapy is most effective when minors feel they can express themselves openly. To foster trust, confidentiality will be maintained between the minor and the therapist. However, parents/guardians will receive general updates on progress and engagement.
• At the start of treatment and throughout its course, the clinician will collaborate with the parent or legal guardian to discuss treatment goals, progress, and any concerns regarding the minor client. If appropriate and at the discretion of clinician and/or BTS, minor client may be involved in this process. This communication will adhere to all applicable laws and regulations.
• Please note that while clinicians are only required to share limited information, the remainder of the minor’s disclosures and session details are protected by privacy and confidentiality guidelines, unless there is a risk of harm or a legal obligation to report.
• Parents and legal guardians should become familiar with all applicable laws and regulations pertaining to minors attending therapy in New Jersey.
• Specific details of sessions will remain confidential unless:
  • The minor is at risk of harming themselves or others.
  • There is suspected abuse, neglect, or danger to the minor.
  • The minor consents to share information.
  • A court order or legal requirement mandates disclosure.
• Open communication between the therapist, the minor, and their guardians is encouraged to ensure alignment on goals and progress.

Parent/Guardian Involvement:

• Active involvement from parents/guardians may be requested to support the minor’s therapeutic process. This could include attending joint sessions, participating in family therapy, or completing supplemental tasks at home.
• Regular parent consultations can be scheduled to discuss concerns, review progress, and explore ways to reinforce positive outcomes outside of therapy. Any charges that may be incurred for such consultations will be explained in advance of scheduling such appointments and payment is expected to be made at time of service.

Appointment and Attendance:

• Parents/guardians are responsible for ensuring the minor attends sessions consistently and on time.
• All aspects of the Cancellation & Attendance Policy outlined in this document apply, unless other arrangements are agreed to in writing between parents/guardians and BTS.

Emergencies:

• In the event of an emergency, the parent/guardian will be contacted immediately using the information provided at intake. Please ensure that contact details are kept up to date.

Custody Matters and Reunification:

• BTS does not engage in legal matters or custody evaluations, determinations of parenting time, or reunification therapy. Our focus is on providing therapeutic services to support the minor's mental health and well-being.
• If these services are needed, parents and legal guardians must seek outside services from an appropriately credentialed professional, in accordance with all applicable laws and regulations pertaining to such matters.

10. COUPLES & FAMILY THERAPY POLICY (only applicable for couples & family clients)

When working with couples or families, therapy focuses on improving relationships, communication, and addressing shared concerns. To ensure a clear and ethical process, the following guidelines apply:

General Information

• Treatment for couples and families is often not covered by insurance plans. While BTS will make every effort to verify coverage for these services, there is no guarantee that insurance companies or third-party payers will approve or reimburse for them. Clients are responsible for any costs not covered by their insurance or third-party payer.
• Although couples or families will be treated as a single unit, one individual will be designated as the primary client for record-keeping purposes. This designation is for administrative use only and does not reflect a greater focus on any one participant in the therapeutic process. All members of a couple or family unit will have equal rights and responsibilities as outlined in this Informed Consent form.
• The clinician and/or BTS reserve the right to terminate or pause services if it is determined that couples or family therapy is not clinically appropriate. This may include, but is not limited to, situations involving abuse, active substance or alcohol use, lack of engagement, or other factors that hinder the therapeutic process. Referrals to alternative services or providers may be offered as appropriate.

Confidentiality:

• Information shared in joint sessions is considered part of the collective treatment record. As part of BTS policy, the clinician and/or BTS does not keep secrets between individual members of a couple or family. If one party discloses information privately that is relevant to the treatment of the couple or family, the clinician will encourage that party to share the information during a session, offering support in the process. If the party chooses not to disclose the information, the clinician may determine it necessary to share it in the interest of maintaining therapeutic integrity and progress.
• Exceptions to confidentiality include risks of harm, abuse, or legal obligations to report.

Consent and Participation:

• All participating members must provide consent for therapy. Participation is voluntary, and each person’s perspective is valued and respected throughout the process. Each member will be required to sign their own individual consent forms that will be part of the clinical record.

Records and Communication:

• Requests for records or information must have the consent of all participants involved in the couple or family therapy and may be provided at the discretion of clinician and/or BTS. BTS does not provide individual assessments, opinions, or documentation that favors one party over another. All standard policies regarding records, communication, and confidentiality apply to couple and family therapy sessions.

11. TERMINATION POLICY

Therapy is a collaborative process, and clients, clinician or BTS may choose to discontinue services at any time. Clinicians and BTS are required to comply with all applicable laws, regulations and ethical guidelines when terminating services with a client.

Some reasons a clinician or BTS may terminate services include but are not limited to:

• Lack of Progress or Goals Have Been Met
• Lack of Client Engagement/Participation
• Client Refusal or Unable to Follow Treatment Recommendations or BTS policies
• Conflict of Interest
• Inappropriate Behavior
• Relocation
• Inappropriate Level of Care or Outside Scope of Practice

In such cases, appropriate referrals will be provided to ensure continuity of care. BTS is committed to conducting the termination process in an ethical and supportive manner. When possible, a notice period will be observed to allow for closure and transition planning.

12. CLIENT RIGHTS AND RESPONSIBILITIES

Client Rights:

1. Respect and Dignity – You have the right to be treated with respect, compassion, and without discrimination.
2. Confidentiality – Your information will be kept confidential in accordance with state laws and professional ethics, except in cases of risk of harm, abuse, neglect, or legal requirements.
3. Informed Consent – You have the right to receive clear, comprehensive information about your treatment, including the risks, benefits, and alternatives.
4. Access to Records – You have the right to request access to your records, with certain legal and clinical limitations.
5. Participation in Treatment – You have the right to actively participate in developing your treatment plan and to ask questions or express concerns at any time.
6. Refusal or Withdrawal of Treatment – You may refuse or discontinue therapy at any time, though it is encouraged to discuss this decision with your clinician.
7. Non-Retaliation – You have the right to express concerns, provide feedback, or file a complaint without fear of retribution.
8. Referral and Continuity of Care – If therapy is terminated, you have the right to receive referrals for continued care. BTS is not liable or responsible for outcome of any referrals provided.
9. Safe Environment – You have the right to receive services in a physically and emotionally safe environment.
10. Cultural Sensitivity – You have the right to receive culturally sensitive and inclusive care.

Client Responsibilities:

1. Active Participation – Engage openly and honestly in the therapeutic process and attend scheduled sessions consistently.
2. Timely Communication – Notify your clinician of any cancellations or changes at least 24 hours in advance. Comply with Cancellation & Attendance Policy.
3. Payment and Fees – Fulfill financial obligations for services rendered, including co-pays, late fees, and out-of-pocket expenses as outlined in the Financial & Payment Policy.
4. Respect for Boundaries – Respect the personal and professional boundaries of your clinician and follow agreed-upon session guidelines.
5. Honest Disclosure – Share relevant information that may impact your treatment and update your clinician on any significant life changes.
6. Commitment to Safety – Refrain from engaging in harmful or threatening behaviors toward yourself, the clinician, or others.
7. Compliance with Treatment – Follow the agreed-upon treatment plan and discuss any concerns or desired changes with your clinician.
8. Understanding Limits of Confidentiality – Acknowledge and understand the limits of confidentiality and the conditions under which information may be disclosed.
9. Respect for Others – Treat all staff, clinicians, and other clients with respect and courtesy.
10. Responsibility for Progress – Take ownership of your growth and healing process by engaging in and practicing skills discussed in therapy.

14. CONSENT TO TREATMENT

This section outlines important information about treatment and seeks your acknowledgment and consent, confirming that your participation in therapy is voluntary and that you are providing informed consent freely, without duress or pressure. Please review the details carefully. If you agree and consent to receive therapy services at BTS, please sign and date below.

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Client Acknowledgment and Consent to Treatment

I, the undersigned client (or parent/legal guardian of a minor client), acknowledge that I have voluntarily sought therapy services at Breakthrough Therapy Solutions (BTS). I understand that therapy is a collaborative process between the client and clinician. While I recognize that therapy may offer benefits such as improved well-being, enhanced coping skills, and healthier relationships, I also understand that outcomes cannot be guaranteed.

By signing this document, I confirm that I have received and reviewed an overview of the policies and procedures outlined in this document. This includes information regarding confidentiality, attendance, cancellations, fees, and my rights and responsibilities as a client, or as the parent/guardian of a minor client.

I acknowledge that I have had the opportunity to ask questions and seek clarification about this informed consent form. My signature below indicates my understanding, agreement, and consent to engage in therapy services as a client or parent/legal guardian of a minor client at Breakthrough Therapy Solutions.

If signing as a parent or legal guardian, I confirm that I have the legal authority to consent to treatment for the minor client. By signing, I consent to treatment and agree to the terms outlined by Breakthrough Therapy Solutions (BTS).

REQUIRED SIGNATURE

(adult client OR parent/guardian of minor client UNDER 14 years old)

ONLY REQUIRED IF MINOR CLIENT IS 14 YEARS OR OLDER, AFTER PARENT/LEGAL GUARDIAN HAS COMPLETED THE ABOVE SECTION WITH THEIR SIGNATURE/DATE

15. NEXT STEPS (for first time clients)

The questions below help us determine which additional forms are necessary for your specific needs. This process reduces the number of forms you need to complete by identifying only those that apply to you. Upon receipt of this form, you'll receive an email with the relevant forms and details about scheduling your first appointment.