We understand that couples therapy begins with an evaluation of our relationship, past, and present. While Megan Szczepanik is deciding whether she is the appropriate therapist for us, we will decide whether we wish to begin couples therapy with her.

We understand that because of the commitment of time and money, plus the potential impact on us and others (see below), it is important to make an informed choice for a couples therapist.

We have read and understand the potential limits of confidentiality, including those imposed by Megan Szczepanik’s policies and by state law, and we have received a copy to keep. [If we have dependent children, we have read and understood the potential limits of confidentiality regarding access to records in child custody cases].

We understand that the information discussed in couples therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners. We agree not to subpoena Megan Szczepanik to testify for or against either party or to provide records in a court action.

We understand all policies as described on the PATIENT INFORMATION sheet and accept them as conditions for entering into couples therapy with Megan Szczepanik. We understand the limits and benefits of using insurance to pay for couples therapy. If we use insurance, we agree to provide all information needed to comply with insurance regulations. We understand that if we use insurance, Megan Szczepanik will not retain control over the information provided to the insurance company.

We agree to share responsibility with Megan Szczepanik for the therapy process, including goal setting and termination. By entering into couples therapy, we accept that we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. We understand that the changes one or both of us makes will have an impact on our partner and on others around us. We accept that such changes can have both positive and negative effects and agree to clarify and evaluate the potential effects of changes before undertaking them. [This is especially true if we have dependent children.]

We agree to pay for all services provided by Megan Szczepanik, including any charges not fully reimbursed by the insurance company. We understand that no insurance company will pay for missed sessions, and we agree to Megan Szczepanik’s policy of charging if we fail to cancel appointments in advance.

By signing below, we agree to accept mental health services from Megan Szczepanik and accept full responsibility for payment for such services.