This Consent and Services Agreement applies if your Provider is an Employee or Contractor of Thriveworks. Some Providers on are independent operators and will have their own agreements.

Consent and Services Agreement:

Welcome to your first session at Thriveworks! Please review this form carefully, and feel free to ask us any questions!

About our Services. It’s our goal to offer a positive, empowering, and life-enriching experience for our clients. The potential benefits of counseling are many and include improved functioning, relationships, self-image, mood, and the attainment of personal goals. However, in some cases persons have reported feeling worse after counseling. Clients understand that healing and growth is difficult, and some discomfort will likely be a part of the counseling process.

Confidentiality. Your confidentiality and privacy is extremely important to us. Thriveworks is considered a “covered entity” under HIPAA, meaning that we comply with HIPAA privacy rules. Our full notice of privacy practices was provided to you in your email confirmation, and can also be found on our website at All communications and records with your counselor are held in strict confidence. Information may be released, in accordance with state law, when (1) the client signs a written consent to release; (2) the client expresses serious intent to harm self or someone else; (3) there is reasonable suspicion of abuse against a minor, elderly person, or dependent adult; (4) for billing purposes; or (5) a subpoena or court order is received. In compliance with ethical codes, including section 2.2 of the AAMFT Code of Ethics, when providing couple, family, or group treatment, your counselor will not disclose information outside the treatment context without a written authorization from each individual competent to execute a release. The client agrees to this policy regardless of who is paying for services, and regardless of who is listed as the ‘identified patient’ for 3rd party payments.

Electronic Communication & Online Counseling. Telephone, non-encrypted email, and videoconference are electronic methods of communication, and some confidentiality risk exists with their use. Our team communicates using these mediums. Occasionally, your counselor, or someone from our team, may follow up with you by telephone or email for scheduling, billing, quality assurance, or other issues. If you would prefer not to be contacted by email, simply inform your counselor and your preferences will be respected. If you and your counselor are participating in distance counseling sessions the counselor will abide by the laws and ethical codes of his/her state of licensure. While a growing base of research has shown that distance counseling services—through various electronic means—can be effective, such services are relatively new in comparison to traditional (in-person) counseling, which has a much longer track record of positive outcomes. Distance counseling may not be appropriate for some clients and for the treatment of some mental health issues.

Scheduling and Cancellations. Appointments can be cancelled/rescheduled as long as 24 hours notice is provided. If less than the required notice is given, the client agrees to pay for the session (insurance will not pay for missed appointments). Please note that we do enforce this policy.

Conflicts. We work hard to ensure that you have a positive experience. However, if a conflict occurs, it is agreed that any disputes shall be negotiated directly between the parties. If these negotiations are not satisfactory, then the parties agree to mediate any differences. Litigation shall be considered only if these methods are given a good faith effort.

Emergency Contacts. Your counselor may establish emergency contacts for you, such as a family member, a mobile phone, or work phone number. These contacts may be used if your counselor perceives a need. If you are in crisis and cannot reach your counselor, please go to your nearest emergency room.

Service Fees. Payment, including insurance co-pays, is due at the time of the service. Client gives the practice permission to charge their credit/debit card on file for any outstanding dues. Clients understand they are fully responsible for all fees if insurance or other vendor does not pay for any reason.

By Clicking that you agree and attest to the following: I have been provided a Notice of Privacy Practices and also I have read and fully understand and agree to honor this agreement.