This group consultation agreement is between the undersigned and Risa Ganel, LCMFT, RLT Certified ++, and RLT Bootcamp Certified who will be referred to as Risa Ganel in this RLT Consultation Agreement.
I understand that Risa Ganel and others in the group can only advise me based on the information I present and the knowledge I have of my client(s). I am aware that I am under no obligation to carry out recommendations. I agree to keep confidential all cases discussed in the group.
I agree that I have independent clinical licensure, I’m working under the supervision of an independently licensed clinician, or I’m a certified coach and understand that I remain completely responsible – ethically and legally – for the decisions I make in my own clinical case or coaching situations. This consultation will provide me with an opportunity to discuss clinical and/or coaching cases and issues about which Risa Ganel may have some expertise, and she may help me consider options for responding, but the comments made for my consideration are not monitored under supervision nor are they mandates.
I also understand that although personal issues relevant to my clinical and/or coaching work may be discussed in the group, Risa Ganel’s consultation services do not constitute psychotherapy.
I understand the potential limits of confidentiality of this relationship. To the extent possible, my case presentations will provide no identifiable patient information. However, I understand that if I provide identifiable information about a situation regarding which Risa Ganel has an ethical or legal obligation to report confidential information, she will inform me at the time and will give me the opportunity to make the report myself.
I understand that the fee for the 10 week Case Consultation group is $140 per two hour group. I understand that I am committing to 10 sessions and that I have 2 payment options:
- Pay $1,400 in full to secure my spot or
- Pay $700 (half) now with the remaining balance due two weeks prior to the start of the group.
I understand that if Risa Ganel cancels a meeting, she will offer a rescheduled meeting time to make up for the cancellation. I understand that if I cancel my attendance for any given consultation meeting, I will not be refunded for that canceled meeting nor will the fee be prorated. I understand that extenuating circumstances may be discussed with Risa Ganel and all decisions outside of this agreed payment schedule are at the discretion of Risa Ganel..
Printed Name:_________________________________________________
Date:_______________
Signature_____________________________________________________
(This document will be sent to you by email and should be signed, dated and sent back to Risa Ganel at risaganel@togethercouplescounseling.com)
