Informed Consents and Service Agreement

Informed Consents and Service Agreement

While the approaches I use aim to help you effectively manage your healing process and personal development from a place of emotional stability and security (ie: inner resources), it can be a challenging path. Therapy often requires recalling experiences, some of which may be unpleasant, in addition to feeling into deep emotions. This approach to “root” healing may also involve making changes that can feel uncomfortable to you and those close to you. With the skills I teach you, in addition to other internal and external resources, you can manage these experiences and changes, and thus attain your goals for this work.

By choosing out-patient care, I acknowledge that I am responsible for my health and well being. In emergency/crises situations or if Elisa Elkin-Cleary, LICSW can not be contacted, I acknowledge that my choices for immediate help and support are to proceed to my nearest hospital emergency room or to call 911/your local emergency number.

Cancellations and Missed Appointments

When you must cancel, please give me at least 36 hours notice. I am rarely able to fill a cancelled session unless I know at least 36 hours in advance. If you are unable to provide at least 36 hours notice when you cancel, you will be charged the full fee for your session. In situations when weather, a true emergency, or sickness prevents you from attending , you will not be charged: I ask only that you call as soon as possible to let me know.


As part of the counseling process, Elisa Elkin-Cleary, LICSW is bound by ethical responsibilities to keep confidential the information shared during the sessions, and in general, she will not release any information without your written permission. There are important exceptions to the confidentiality of the counseling relationship. Ms. Elkin-Cleary is required by law to reveal certain information under the following circumstances:

  1. Client’s disclosure of serious intent to do harm to self or others.
  2. Client’s disclosure of child abuse or my suspicion of child abuse, elder abuse, or dependent adult abuse.
  3. If a court of law orders the release of specific information.

Ms. Elkin-Cleary must obtain an individual’s authorization to use or disclose psychotherapy notes with the following exceptions:

  • Ms. Elkin-Cleary, who originated the notes may use them for treatment. This includes consult with other health and mental health professionals about a case.
    During consultations, Ms. Elkin-Cleary makes every effort to avoid revealing the identity of clients. The other professionals are also legally bound to keep the information confidential.
  • Ms. Elkin-Cleary may use for educational purposes, without an individual’s authorization, the psychotherapy notes, in training situations where names and identifying information are changed for the protection of the client.
  • Additionally, Ms. Elkin-Cleary may use the psychotherapy notes to defend herself in legal proceedings brought by the client, for Health and Human Services to investigate or determine the covered Ms. Elkin-Cleary’s compliance with the Privacy Rules.

For your information in regards to HIPAA rights:

I have read, understood, and accept the practice policies and HIPAA rights and agree to the conditions.

Consent for Treatment

I agree to enter treatment with Elisa Elkin-Cleary, LICSW. If you have any questions about this practice’s policies or about psychotherapy, please ask before signing below. Your signature indicates that you have read each of this practice’s policies and agree to enter therapy under these conditions. Further, it indicates your understanding that Ms. Elkin-Cleary may terminate therapy if you do not comply with the policies, or if she feels you are not benefiting from treatment where upon she will make an appropriate referral.

My electronic signature represents that I have read, understood and agree to all the above terms and conditions.