Consent for treatment - therapist Dianne Fisher-Griffith

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Ephesians Professional Counseling

Dianne Fisher-Griffin, MS, RN, LCPC

State Licensed Clinical Professional Counselor, Registered Nurse


Name of Client*


A Maryland Licensed Clinical Professional Counselor with a Master' s of Science Degree in Pastoral Counseling; 2010 graduate of Loyola University Maryland - accredited by the American Counseling Association CACREP (Council for the Accreditation of Counseling & Related Educational Programs). I Received a Bachelor of Science Degree in Nursing from Fairleigh Dickerson University in 1976.

Specialty counseling involves working with a broad spectrum of mental health issues including Anxiety, Depression, Post- partum Depression, Panic, Low Self Esteem, Grief and Loss, Spiritual issues, Anger Management, Stress Management, Life Transition/Personal Coaching, Individual and Group Therapy.


I believe counseling is a collaborative effort between the counselor and the client; A meaningful change can be achieved through commitment, hard work, honesty and time. Establishing a positive trusting relationship will facilitate an opportunity for healing past hurts, thus allowing clients to understand themselves better, set personal goals and be supportive in a safe, nonjudgmental environment which will facilitate a positive transformation of a healthy, integrated fulfilled life.

My counseling approach incorporates a variety of therapeutic principles to create a treatment program to meet the specific needs of the client with an emphasis on Cognitive Behavioral Therapy and Client-Centered Therapy. Clients are encouraged to work with your counselor in the development of your treatment plan and be informed of any new modes within your treatment process. The benefits to be gained from counseling are vast. Some benefits are an improved outlook on life, more effective coping skills, greater understanding of yourself, and better communication tools that will not only have positive effects on your relationships, but through many spheres of your life.

For therapy to be most effective it is important that clients attend sessions on time and on a consistent basis. It is best to discuss termination with your counselor in a final session before a decision is made to end counseling.

As a licensed practitioner, I must maintain registration and or certification with the Maryland State Department of Health for the protection of public health and safety. As a counseling client, you have the right to choose a counselor who best suits your needs and purposes. The first session is an opportunity for both client and counselor to evaluate whether this professional relationship is right for each party.


As a client, you have the right to request referrals for other therapy services when necessary, request a copy of your records, participate in setting goals and evaluating progress meeting them, receive a copy of the code of ethics to which your counselor adheres and contact the appropriate professional organization if you have complaints about professional counseling services rendered.


All information shared in therapy is confidential. The counselor does not release information about a client without the client's written permission, except in the case of imminent danger to self or others, suspected of child/dependent abuse, court order or where otherwise required by law.

Cases are occasionally discussed/conferred with other professional counselors to obtain feedback and provide alternative treatment plans and continuity of care (for supervision). In these cases, identifying information is not disclosed and only relevant information is discussed.


Depending on what your insurance allows and authorizes, the psychotherapy sessions are varied in length between 40 and 50 minutes in length. The initial session is 70 minutes in duration. It is your benefit to arrive a few minutes in advance of the appointment time. Since counselor has additional sessions scheduled after yours, the session must end at the appointed time regardless of your arrival time. Please understand that when you make an appointment, I am reserving that time for you. If you are late, there may or may not be a possibility of extending your session. Regardless you will be charged for the full session.


The initial session is 70 minutes in duration at a fee of $180. My fee is $120 per individual session. All payment is due at the time services are rendered. Payments may be made in the form of cash, check or credit. A $42 service charge will be levied on all checks returned by a bank for insufficient funds. Most insurances are accepted see checklist of in network companies. Insurance company will be billed unless otherwise agreed upon. You are responsible for any balance that insurance does not cover and agree to pay any unpaid balance on your account in a timely manner.


When an appointment is scheduled, that time is reserved for you. If the appointment is missed or canceled without sufficient notice, the therapist is unable to make use of that time and could be spent with another client; therefore, it is necessary for therapist to charge a fee of $65 for late cancellation (less than 24-hour notice/missed appointment.


This information is required by the Board of Professional Counselors and Therapists which regulates all certified and licensed counselors and therapists.

Board of Professional Counselors and Therapists. (410) 764-4732
4201 Patterson Ave. Baltimore, MD 21215.


Signature below indicates I have thoroughly read, understand and agree with all the policy and procedure statements above and obligates both client and counselor to abide by all rules and regulation as listed above.

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