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Ind Spt

Consent for Services

You are requesting mental health services from growURpotential and we do ask you to confirm your understanding of your rights and obligations by reviewing this form and granting consent. If you have any questions, please ask your mentor, case manager, or therapist to support you. 


Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.

Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional.


Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.


The content of sessions with our counselors is considered to be lawfully confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client. Exceptions to this confidentiality are as follows:

~Duty to Warn and Protect: When a client discloses intentions or a plan to harm another person, the counselor is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the counselor will make reasonable attempts to notify the family of the client.

~Abuse of Children and Vulnerable Adults: If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the counselor is required to report this information to the appropriate authorities. This includes prenatal exposure to controlled substances that are potentially harmful.

~Agency collaboration for training purposes: Our counselors hold a Master's Degree related to counseling and are Registered Associate Therapists with the California Board of Behavioral Sciences. The services provided by our counselors are supervised by our Clinical Team. Your case will be explored for training purposes, within this agency only.


We are a nonprofit agency and all of our clients have access to therapy at rates substantially lower than most providers in Los Angeles. We are proud to be a valuable resource to many and we are happy you have chosen to partner with us. Our agency provides counseling sessions based on a monthly agreement. Your monthly agreement must originally be for 4-weekly sessions per-month AND when it becomes appropriate your session frequency will be reduced to biweekly sessions. The fee for this monthly agreement is based on our sliding scale and is nonrefundable.

You may ask anyone on your care team to explain the full terms of this policy in writing and ask for your approval before any charge is accomplished. You may email i to cancel your session agreement at any time. We do require that you keep a credit or debit card on file. Your fee will become a recurring charge on your card-on-file until you discontinue sessions. Our primary goal is to elevate commitment to services. We have a higher request for sessions than we have open slots for sessions and we must serve the community in a responsible way.


The Board of Behavioral Sciences receives and responds to complaints regarding services provided by individuals licensed and registered by the board. If you have a complaint and are unsure if your practitioner is licensed or registered, please contact the Board of Behavioral Sciences at 916-574-7830 for assistance or utilize the board’s online license verification feature by visiting

If you feel any care partner at this agency has engaged in improper or unethical behavior, you encourage you to reach us by emailing i or you may contact the Board of Behavioral Sciences at 916-574-7830 or the US Department of Health and Human Services.




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