New Client Forms
Therapy Informed Consent
Please read each section carefully before signing below.
Nature of Services
Psychotherapy and coaching are professional services provided by E Jean DuBose, LCSW. Sessions may include talk therapy, holistic techniques, energy work, guided imagery, mindfulness, and other integrative approaches tailored to your individual needs. The therapeutic relationship is collaborative, and your active participation is essential to the process.
Confidentiality
All information shared in sessions is strictly confidential. Exceptions to confidentiality exist as required by law, including: (1) imminent risk of harm to yourself or others; (2) suspected abuse or neglect of a child, elder, or dependent adult; (3) a court order requiring disclosure. In these circumstances, disclosure will be limited to what is necessary.
Telehealth & Virtual Sessions
Telehealth services are provided via secure video or phone platforms. You understand that technology limitations may occasionally affect session quality. You agree to participate in a private, confidential location and to notify your therapist if a third party is present. Telehealth psychotherapy is available only to Arizona residents. Coaching services are available nationwide.
Fees & Payment
Session fees are due at the time of service. We accept most major insurance plans. Please note: we no longer accept Cigna, Blue Cross Blue Shield, United Healthcare, or Medicare. You are responsible for any co-pays, deductibles, or non-covered services. A fee may be charged for late cancellations or missed appointments without 24-hour notice.
Cancellation Policy
Please provide at least 24 hours notice if you need to cancel or reschedule your appointment. Late cancellations or no-shows may be subject to a fee. Repeated missed appointments may result in termination of services.
Emergency Procedures
If you are experiencing a mental health emergency, please call 911 or go to your nearest emergency room. You may also contact the 988 Suicide & Crisis Lifeline by calling or texting 988. Your therapist is not available 24/7 and cannot guarantee immediate response outside of scheduled session times.
Voluntary Participation
Your participation in therapy or coaching is entirely voluntary. You have the right to withdraw consent and discontinue services at any time. You are encouraged to discuss any concerns about your treatment with your therapist.