JAN SANTORA-FARRAR, MA
Licensed Mental Health Counselor #00010966
jan.santora1@gmail.com
206.233.1021 

Collateral Therapy Consent
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I,_________________________________________,(collateral participant) have been invited by ________________________________________(client) to attend one or more of the client’s psychotherapy sessions with Jan Santora-Farrar.  I understand that the purpose of my attending is to assist the client and Jan Santora-Farrar in the client’s treatment and not to seek psychotherapy for myself.  I understand that my role as a collateral ally in the psychotherapy is to:

a) provide information about the client, both factual and from my personal perspective;
b) participate in exercises during sessions that are intended to help further the client’s treatment;
c) support the client during treatment in other ways.

I understand that my participation is voluntary and that at any time I can withdraw, decline to answer any question or participate in any exercise.  I certify that I do not have a person or client relationship with Jan Santora-Farrar.  I am not responsible for any therapy fees, except in those cases, such as parent or legal guardianship, in which I would normally be responsible for the client’s therapy fees.

I understand that what I say in session(s) may be discussed between Jan Santora-Farrar and the client.  (Note: It is sometimes possible to maintain the privacy of our communications.  If you wish to maintain some privacy concerning some aspect of our communications, we should discuss if before any information is communicated by you).

As a collateral ally I understand that I have certain rights and requirements pertaining to confidentiality, as well as some limits to that confidentiality.  I am expected to maintain the confidentiality of the client.  I understand that although Jan Santora-Farrar will not maintain a chart on me nor make any diagnosis, notes about me which pertain to my relationship with the client may be entered into the client’s charts as well as some of my comments about the client.  Because the client has rights to her/his confidentiality, I may not request to access that chart without written consent of the client.  The client, however, pursuant to state and federal laws, can access her/his chart.  I understand the following exceptions to confidentiality, which pertain to both the client and myself:

If Jan Santora-Farrar suspects abuse or neglect of a child or vulnerable adult, she is required to file a report with the appropriate agency;

If Jan Santora-Farrar believes that I am a danger to myself (suicidal) she is required to take actions to protect my life;

If I threaten serious bodily harm to another, Jan Santora-Farrar is required to take necessary actions to protect that person;

If a court requires that Jan Santora-Farrar submit information or testify in a case involving me or the client, she must comply.  Please note that Jan Santora-Farrar will do so only if the court requires it, not merely if an attorney requests information;

If insurance is used to pay for treatment, the insurance company may require Jan Santora-Farrar to submit information about the treatment before they will pay for treatment.

I understand that my role as a collateral may create some anxiety or emotional distress in me.  It may also expose or create some emotions in my relationship with the client.  I understand that if I find myself experiencing any emotional difficulties and I am not currently in psychotherapy, I should let Jan Santora-Farrar know so that she can suggest resources or referrals to me.

I, ______________________________________(signature of client) give permission for

________________________________________(collateral participant) to attend one or more of my psychotherapy sessions.

(Printed name of client) _______________________________________________________

(Signature of collateral participant) ______________________________________________

(Printed name of participant) __________________________________Date_____________