Therapeutic Agreement

    The following terms represent an agreement between you, the client, and me, Jean Blacklock, on (YYYY-MM-DD).

    1. Confidentiality

    Everything you share with me will be confidential between you and me, with three exceptions:

    (1) If you disclose to me a situation of physical harm, neglect or sexual abuse of a minor;
    (2) If you disclose a situation in which you or another person is in imminent severe risk of
    physical injury; or
    (3) If my records are subpoenaed by a court order.

    I will speak to another healthcare provider about our work only at your request and upon you signing a consent form.

    To provide my clients the best therapy, I will discuss my work with a clinical supervisor. I will keep all names and identifying material confidential.

    2. Fees and session durations

    My fee per 60-minute session is $125. Fees may be paid by email money transfer on the day of our session.

    3. Cancellation policy and fees for cancelled sessions

    Sessions can be cancelled up to 24 hours before the session without payment. Sessions cancelled within 24 hours are fully payable, please. I will make an exception to the missed session fee if an emergency arises within 24 hours of our session.

    4. Therapist absence

    If my availability changes after you have booked a session, I will give you as much notice as possible. If an emergency arises and I cancel within 24 hours of our session, your next session will be at no charge.


    Please sign below to indicate that you agree to these terms and that you consent to therapy with me. By signing this agreement, you are saying that you have read and understood the terms and that there has been an opportunity to discuss these with me prior to beginning your therapeutic work together.

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