Bright Horizons
Wellness Counseling

Consent To Treatment

• Please review this document and, if you agree with the content,
  print out a copy, sign at the bottom, and mail to:
  
  Bright Horizons Wellness Center
  Eric Rutberg, LCPC
  PO Box 1082
  Wilton, ME 04294

  Email it to: eric@yourwellbeing.org

  Or Call 207-645-9700 for more information

  ---

  I understand that therapy via the Internet is an experimental modality and there
  is not yet sufficient empirical evidence to show that it works. There is, however,
  evidence that traditional forms of face to face therapy DO work. Therefore I may,
  in addition to web counseling, seek out a qualified therapist in my area if that is a
  viable option for me.

• I have chosen this mode of therapy because more traditional face to face therapy
  is not appropriate for me for reasons of mobility limitations, geographic isolation,
  or because there are circumstances which make communication via keyboard
  preferrable to verbal communications.
•  
• I understand that, for all legal and regulatory purposes, the services I am provided
  via this method of therapy will be considered to be provided in the state of Maine,
  United States of America. I further understand that Counselorsare subject only to
  the laws and regulations of that state and country and that he subscribes to the Code
  of Ethics of the National Board of Certified Counselors, and is subject to sanction by
  the NBCC for violations. I also understand that he subscribes to the code of ethics for
  online practices of the National Board of Certified Counselors.
• I hereby certify that I am of the legal age of consent according to the laws of my home
  state, province, or country.
•  
• I understand that, pursuant to the laws of the state of Maine and in keeping with
  US Supreme Court decisions, my therapist is required to violate my confidentiality
  and make appropriate notifications if he believes that I may intend to hurt myself or
  another person or that I am involved in child abuse, child neglect, spouse abuse, or elder abuse.
•  
• I understand that it is unlikely that my insurance provider or national health care plan
  will reimburse me for the cost of this therapy and I chose to be a "private payer" and
  pursue any potential reimbursements on my own.

  
  Printed name:_____________________________________________________

  Address:_________________________________________________________

  ________________________________________________________________

  ________________________________________________________________

  Telephone number: (area code + Number) ______________________________

  Signed__________________________________ Date____________________