EMPOWERMENT THERAPY

Email Address: *

Agreement and Consent Form

Instructions: Please read the following, fill in the required information, and click submit.

Hello. Welcome to Empowerment Therapy Online at www.empowermenttherapy.com. This Agreement and Consent Form is being provided to you, a client, in order to inform you about Online Therapy and answer some questions you may have. But it is highly recommended that you read the FAQs section, as well as other informational sections to acquire more details about my services, my qualifications and the most effective and efficient procedure in obtaining these services.

As a client of Brian J. Hubbard LICSW, BCD,at Empowerment Therapy Online, I understand that online therapy is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither Brian J. Hubbard, LICSW at www.empowermenttherapy.com nor me. Internet availability may be limited or disrupted by things such as server problems, caused by software or hardware malfunction, natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth), and other technical problems beyond the control of Brian J. Hubbard, LICSW at www.empowermenttherapy.com and myself. If something like this were to occur, and a telephone appointment has been scheduled, any scheduled appointments would be re-scheduled at no additional cost.    If any of the disruptions described above that are beyond the control of Brian J. Hubbard and myself, it is my responsibility to re send the message within a 24-48 hour period so the sender will know that the message has been received  In fact, it is desirable that I send immediate replies to messages in response to messages received from Brian J. Hubbard at www.empowermenttherapy.com.  The e-mail message needs only to contain the words ‘message received’ on the subject line to confirm that a message has been received.  Whenever Brian J. Hubbard at www.empowermenttherapy.com sends a message, an automated request notifying the recipient of the message has the option of sending an automated reply to confirm that the message has been received.  I understand that I am required to send the auto reply so that Brian J. Hubbard will have confirmation that the message has been received.  Any complication, delay or other problem arising from the refusal to send the auto-reply is not the fault of Brian J. Hubbard at www.empowermenttherapy.com.

Also, each message sent by Brian J. Hubbard, LICSW from www.empowermenttherapy.com will contain the following text at the end of the message:

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This message is intended only for the designated recipient(s).  It may contain confidential or proprietary information and may be subject to the attorney-client privilege or other confidentiality protections.

If you are not a designated recipient, you may not review, use, copy or distribute this message.  If you receive this in error, please notify the sender by reply e-mail and delete this message.  Thank you.

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[this is why it is so important that you provide your e-mail address with precise accuracy; Brian J. Hubbard, LICSW at www.empowermenttherapy.com can not be held responsible for messages being sent to erroneous places if the wrong e-mail address is provided]

I understand that I must be at least 18 years of age to consent for services by Brian J. Hubbard, LICSW at www.empowermenttherapy.com (If not, a parent or legal guardian must contact Brian J. Hubbard at www.empowermenttherapy.com and provide a written consent for services). As a client ofBrian J. Hubbard, LICSW at www.empowermenttherapy.com, I declare that I am free of suicidal and/or homicidal thoughtsand/or intentions. I also understand that Brian J. Hubbard, LICSW at www.empowermenttherapy.com may be required to violate my confidentiality to make appropriate legal notifications if he reasonably believes I am involved in child abuse or neglect, or if I intend to harm myself, or if I am involved in criminal activity. This is discussed in more detail on the Confidentiality and FAQs sections of www.empowermenttherapy.com. If a breach of confidentiality were to occur, such actions would be pursuant to the laws of the State ofRhode Island. As a note, the State of Rhode Island does not mandate that clinical social workers or other types of mental health clinicians notify authorities when a client makes a threat against another individual, UNLESS that threat is professionally assessed to be serious in intent, has a thought out plan and the client presents a psychological demeanor and/or profile that reflects obvious poor judgment, poor impulse control, rage and/or hopelessness.

For all legal and regulatory purposes, the services of Brian J. Hubbard, LICSW at www.empowermenttherapy.com are provided from the State ofRhode Island. I further understand that Brian J. Hubbard, LICSW at www.empowermenttherapy.com is a Licensed Independent Clinical Social Worker-Advanced Clinical Practitioner (LICSW) in the States of Rhode Island and that he is subject only to the laws and regulations of the state of Rhode Island. Accordingly, Brian J. Hubbard, LICSW at www.empowermenttherapy.com will only be held liable under the Rhode Island Social Work Licensing law and statutes.

I realize that I will be charged $20.00 US Dollars for each 15 minutes of time  that Brian J. Hubbard, LICSW at www.empowermenttherapy.com spends working with me (unless otherwise stated and mutually agreed upon by Brian J. Hubbard at www.empowermenttherapy.com and myself before services are rendered). I need to recognize that during the process of psychotherapy, psychological discomfort may arise (as difficult issues are addressed and worked through). This is an often times necessary part of psychotherapy, even though it does not guarantee resolution of any kind or assure success for therapy, either explicit or implied. This means that there is no guarantee as to the outcome from the services of Brian J. Hubbard at www.empowermenttherapy.com a successful outcome also depends on the constructive, active participation of myself. This includes limitation or restriction, of any guarantee, for information, counseling, uninterrupted access, and other services provided through Brian J. Hubbard, LICSW at www.empowermenttherapy.com. In addition, as a client of Brian J. Hubbard, LICSW at www.empowermenttherapy.com , I can end services at any time, for any reason, without prior notification or explanation to Brian J. Hubbard, LICSW at www.empowermenttherapy.com. (Although a note explaining any decision to stop services would be greatly appreciated).

I also acknowledge that, although Brian J. Hubbard, LICSW at www.empowermenttherapy.com has taken a significant number of steps to ensure the confidentiality of Online communication, these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify Brian J. Hubbard, LICSW at www.empowermenttherapy.com from all suits, claims, and other actions originating from psychotherapy provided through Brian J. Hubbard, LICSW at www.empowermenttherapy.com.

Optional Questionnaire

The following information is being collected for professional purposes only. Responding to questions is voluntary. Confidentiality of all submitted information will be strictly maintained; the details you supply will not be released to anyone other than as mandated by law.

All questions are optional.

Please answer as many questions as you are comfortable responding to.

Name:
Gender:	- choose - Male Female
Age:
Marital Status:	- choose - Single Married Divorced
Occupation:
Employment Status:	- choose - Employed Unemployed Other
Education Level:	- choose - High School Undergraduate Graduate Other
Please briefly describe the problem(s) that you would like to discuss or work through:
How severe would you rate your symptoms? - choose - Mild Moderate Severe Very Severe
Are you currently getting treatment from a mental health professional?
	Yes No
If yes, please explain:
In the past, have you been treated by a mental health professional?
	Yes No
If yes, for what?
What was the outcome?
Are you currently taking any psychotropic medication(s)? (e.g. anti-depressants or anti-anxiety medication)?
	Yes No
If yes, please list:
Have you taken any psychotropic medication(s) in the past?
	Yes No
How would rate the frequency of your alcohol intake?
	- choose - None Light Moderate Heavy
How would rate your nicotine intake?
	- choose - None Light Moderate Heavy
Do you use "recreational drugs"?
	Yes No
If yes, please list:
How would you rate your overall health?
	- choose - Poor Fair Moderately Healthy Excellent Health
Do you have any medical problems that you think contribute to your present situation?
	Yes No
If so, please briefly describe.
Do you have a permanent physical disability (blindness/visual impairment, deafness/hearing impairment, mobility impairment-spinal cord injury, multiple sclerosis, amputation, severe arthritis  and related mobility impairments,organic mental disability-CP, Traumatic Brain Injury)and/or chronic medical condition (e.g. diabetes, cardiac/circulatory problems, Parkinsons, renal/kidney, hepatitis,auto-immune diseases, lung disease, cancerphysical disfigurement-genetic, burn victim, arthritis, scoliosis, gastrointestinal-colostomy, upper GI)  that you have difficulty coping with and would benefit from Empowerment Therapy?  (please read section ‘About Empowerment Therapy)
	Yes No
Have you experienced a significant or traumatic loss (e.g. loss of loved one by death/divorce, loss of job/home/financial security, traumatic event-accident, abuse, rape, natural conditions, wars, terrorism,other acts of violence)  that is difficult to cope with and could benefit from Empowerment Therapy? (again, please read section ‘About Empowerment Therapy’)
	Yes No
Enter any other comments here: