Cherie Lindberg

Cherie Lindberg Informed Consent For Consultation

Your Name

Consultant defined: Brings expertise in a particular area in which a consultee needs or wants to improve. Consultants work with the consultee, student, organization, healer, business person in partnership to ensure outcomes that support goals and a strategic plan of the individual. I wish to receive consultation services from: Cherie Lindberg, LPC, NCC

I understand that these consultations do not constitute clinical supervision and that I remain completely responsible – ethically and legally – for the decisions I make in my own clinical practice with my clients. My consultant will provide me with an opportunity to discuss clinical cases and issues about which s/he may have some expertise, and s/he may help me consider choices for responding, but the comments made for my consideration are not supervision mandates.

I also understand that although we may sometimes need to discuss personal issues that may be relevant to my clinical work, these consultation services do not constitute psychotherapy.

I understand the potential limits of the confidentiality of this relationship. To the extent possible, my case presentations will provide no identifiable client information. However, I understand that if I provide identifiable information about a situation and my consultant has an ethical or legal obligation to report, s/he will inform me at the time and will give me the opportunity to make the report myself.

I understand that if my consultant becomes aware that she knows or has a prior relationship with a presented client(s), or if she believes she has a potential conflict of interest with our relationship, she will notify me of that fact immediately and will cooperate in helping me find a referral for further consultation.

My signature verifies that I understand agree to pay for charges incurred. I have read this information above. By signing this document I am certifying that I understand and agree to follow the policies listed above.

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