At Refreshing Waters Counseling & Consulting we offer a variety of therapeutic interventions to help you overcome the symptoms you have come to us for help with. We carefully select the interventions that are most suited to your situation and wherein have the best possible outcome for you.

I consent to participate in the evaluation and treatment offered to me by Refreshing Waters Counseling & Consulting. I understand that either RWCC or I may discontinue treatment at any time. My provider will do their best to fully advise me of the treatment options available to me. I acknowledge there is no guarantee that I will be cured or that a specific treatment modality will be effective for me personally. I intend for this consent form to cover the conditions I present with as well as any future conditions for which I seek treatment.


It is important for you to know there are both benefits and risks involved in counseling and treatment. Some issues being discussed may cause an increase in symptoms particularly during the early stages of counseling. Discussing unpleasant situations/memories and experiencing uncomfortable feelings are considered risks of therapy. This is a normal part of the process of growth and change. Most people who take the risks involved in counseling find that it has been beneficial to their wellbeing and relationships. The possible risks of counseling and treatment include:

• Distressing unresolved memories/feelings that may surface during or after counseling sessions.
• Unexpected material to be linked to topics discussed during counseling sessions.
• Progressing in counseling and making personal changes in your beliefs and behaviors can be disruptive to the relationships you
already have.
• The processing of emotional material may continue via memories, feelings, physical sensations, dreams and flashbacks following
counseling sessions.
• Physical and/or emotional exhaustion following EMDR or ART sessions
• Recalling memories, but the painful emotions, physical sensations and disturbing images may no longer be present
following EMDR or ART sessions. (Potentially relevant in cases of testimony being required.)


You must be seen at this clinic at least every 90 days or your case will be discharged from active services. If you decide to return for
services after that time you will need to complete the intake process again.

Refreshing Waters Counseling & Consulting schedules on a term basis to insure you have access to providers on a regular basis.

If you have questions or need to communicate information to your therapist between appointments, please use your secure
OnPatient portal or leave a message on the main number and we will respond as soon as we are able.

We do not have an after-hours answering service. If you have an emergency, please contact 911 or go your local Emergency Room.

If you are dissatisfied with any service you have received, please talk to us (receptionist, billing personnel, therapist or supervisor).
You can also submit concerns to the anonymous suggestion box. Your feedback is taken very seriously. It is our policy to actively
engage in ongoing improvement in our practices and policies.

In certain circumstances we may decide to terminate our professional relationship. Reasons for termination may include the
following: failure to improve under our care after a reasonable amount of time, abuse of staff or providers, you experience a change
in insurance provider that we are not able to contract with, or an unpaid balance without a payment agreement plan.

By signing below, I agree to the above information and understand their meaning and ramifications.

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