6. If you request it, any part of your record in the files can be released to any person or agency you designate. I will tell you at the time whether or not I think releasing the information in question to that person or agency might be harmful in any way to you.

7. You should also know that there are certain situations in which I am required by law to reveal information obtained during counseling to other persons or agencies without your permission. Also, I am not required to inform you of my actions in this regard. These situations are as follows: (a) If you threaten grave or bodily harm or death to another person, I am required by law to inform the intended victim and appropriate law enforcement agencies; (b) If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in that order; (c) If you reveal information relative to child abuse, child neglect, or elder abuse, I am required by law to report this to the appropriate authority; and (d) If you are in therapy by order of a court of law, the results of the treatment ordered must be revealed to the court.

8. You have the right to know about the possible harmful results of counseling. In my years of psychotherapeutic service delivery and supervision, the only clear harm I have witnessed has resulted from clients' insistence on using medical insurance for psychotherapy. Harmful events included: denial of insurability when applying for medical and disability insurance due to DSM-IV diagnosis (mental illness diagnosis, which are usually required for reimbursements under medical insurance); company (miss) control of information when claims are processed; loss of confidentiality due to the large number of persons handling claims; loss of employment, and repercussions of diagnosis in situations which require truthfulness about "mental illness", including driver's licenses applications, concealed weapon permits, and job applications.

1. Counseling and therapy will seek to meet goals established by all persons involved, usually revolving around a specific presenting problem. A major benefit that may be gained from participating in counseling includes a better ability to handle or cope with marital, family, and other interpersonal relationships. Another possible benefit may be a greater understanding of family and personal goals and values; the may lead to a greater maturity and happiness as individual and increased relational harmony. Other benefits relate to the probable outcomes resulting from resolving specific concerns brought to counseling.

2. In working to achieve these potential benefits; however, counseling will require that firm efforts be made to change and may involve the experiencing of significant discomfort. Therapeutically resolving unpleasant events and relationship patterns can arouse intense feelings. Seeking to resolve problems can similarly lead to discomfort as well as relationship changes that may not be originally intended.

1. I agree to enter into therapy with Gary Mauldin, Ph.D.

2. I understand that I can leave therapy at any time and that I have no moral, legal, or financial obligation.

3. A twenty-four hour notice is requested for cancellation of a scheduled session. Please contact Dr. Mauldin at the telephone number listed above.

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