Client Responsibilities while
receiving Gay Counseling Services
( Please print out a copy to sign and mail, and a copy for your records. )
Agreement & Limitations of Service
I am requesting on-line counseling services from David Shannon, MSW, LICSW, as described at his website http://www.gaytherapistonline.com. This counseling will be done through e-mail messages, instant messaging or chat programs, according to what we arrange. Telephone consultation may also be available.
I understand that the counseling services so provided are not the same as psychotherapy, which would require in-person, face-to-face contact.
I understand that counseling services provided over the internet may not be as private or confidential as they would be in a closed door office setting. If I have concerns about ensuring that the counseling provided on-line could not be intercepted or retrievable by a third party, I will communicate this to David Shannon. I will cooperate in researching technological and software solutions for this problem. Either party may terminate the counseling relationship, if reasonable and affordable ways to ensure additional confidentiality and privacy cannot be found and implemented.
I understand that emergency crisis service cannot be provided effectively over the internet, and that David Shannon is only available for pre-scheduled, written communication as described above, unless pre-scheduled telephone consultation is agreed upon by both parties. I will be responsible for my own safety, and I will seek local help if I am in a crisis situation that might cause me to harm myself or others. I agree to develop a local crisis plan, and will communicate that to David Shannon, upon request.
I understand and agree that the services provided shall originate in, are provided in, and shall be governed by, the laws and regulations of the state of Minnesota, USA..
I have been informed that David Shannon holds license #13397, as a Licensed Independent Clinical Social Worker (LICSW), which is issued by the Board of Social Work in the state of Minnesota, USA. Their address is:
Board of Social Work
Suite 340
2829 University Avenue, SE
Minneapolis, MN 55414-3239
Fees will be within the range specified on the above website. If I cannot pay the highest fee in that range, I understand that David Shannon may request, and I will provide, accurate information about my income from all sources, as well as my basic living expenses. Once a fee is agreed upon, I agree to pay that fee for services I request, either prior to the services being provided, or promptly thereafter, if such an arrangement has been agreed to in writing by myself and David Shannon.
If I schedule an on-line appointment and I do not keep, utilize or "attend" that appointment, without at least 24 hours notice, I understand that I may be charged for that time, and I agree to pay such fees as may be charged for that time.
Unless arrangements have been made to prepay, using my Visa or MasterCard, I will send such payment(s) to David Shannon, Post Office Box 1251, Mankato, MN 56002-1251. This address, and this method of payment, is subject to change, at the sole discretion of David Shannon, following notice of such change, provided to me in writing. Failure to pay such fees in a timely manner may result in termination of service.
Written communication, including agreements, notifications and any other contractual issues, may be sent by e-mail. I agree to acknowledge receipt of any such e-mail communications. Either party may request that a copy of such communications also be sent via regular surface postal delivery.
___________________________________________________________________________________________________________
I have read, I understand, and I agree to the conditions in the above statement.
____ I am 18 years of age or older.
____ I am younger than 18. My age is ____
_______________________________ _________
Legal name Date
I am also known as:
_______________________________ _________
( Alternate name, if applicable ) Date
Agreement and Limitations
© David E. Shannon
April 23, 2000