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Consent and Policies

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PLEASE READ & CHECK THE BOX TO CONSENT for to the services of Blythe Tucker Zemel. This document serves to inform you of the nature and scope of services provided, as well as to outline your rights and responsibilities in the counseling process. By signing this form, you acknowledge that you understand and consent to the terms of the agreement. Please ask questions if anything is unclear. Nature of Counseling Services I, Blythe Tucker Zemel, am currently enrolled in the Master's program for Clinical Mental Health Counseling at the University of the Cumberlands. As part of my training, I am providing counseling services under the supervision of _________________________ who oversees my work and provides guidance. During our sessions, we will work together to address your concerns and goals. The counseling process may involve discussions of difficult topics and emotions, and we will work collaboratively to explore and understand your thoughts and behaviors. Supervision and Case Review As an intern, I am required to participate in regular supervision sessions with my supervisor. These sessions are confidential, but for the purpose of supervision and professional development, your case may be discussed in a de-identified manner (meaning your identifying information will be kept confidential). Your Rights You have the right to: ● Ask questions about the counseling process. ● End counseling at any time without penalty. ● Request a copy of your records. ● Request a release of information if you wish for your counseling records to be shared with another provider or individual. Consent to Treatment By signing this document, you agree to engage in counseling services with me, Blythe Tucker INFORMED CONSENT Zemel. You understand that I am a graduate student under supervision and that my supervisor may be involved in reviewing your case. You also acknowledge that you have been informed of your rights to confidentiality and the limitations of that confidentiality. Consent for Communication I may need to communicate with you outside of our scheduled sessions (e.g., reminders, updates). Please indicate below your preferred method of contact: ● Phone ● Email ● Text Message Acknowledgement of Informed Consent I have read and understand the above information regarding counseling services, confidentiality, and HIPAA compliance. I acknowledge that I have had the opportunity to ask questions and that I am voluntarily consenting to participate in counseling. Acknowledgement of Understanding By signing below, you affirm that you have understood the contents of this Informed Consent and HIPAA Confidentiality Agreement and consent to receive counseling under the outlined terms.

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