Consent for treatment - therapist Belita Proctor

"*" indicates required fields

Ephesians Professional Counseling

Belita Proctor, MS, CRC, LCPC

State Licensed Clinical Professional Counselor, Certified Rehabilitation Counselor


Name of Client*


As a Maryland State Licensed Clinical Professional Counselor, holding a Master of Science degree in Rehabilitation Counseling from Virginia Commonwealth University, the Maryland State Department of Health requires that I maintain records, provide disclosure information to all clients, and that I make the following statement to clients:

As a paid counseling 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 or not this particular professional relationship is right for each party.


My counseling approach is based on an eclectic model and is primarily influenced by Cognitive Behavioral Therapy, Client Centered Therapy, and Gestalt Therapy. During therapy you, the client, will work together with this counselor to assess where you are experiencing difficulties and what goals you have for therapy. This may require several methods including the intake process, tests, homework, and open conversation between counselor and client. By establishing a positive and trusting relationship, this counselor will attempt to assist you with mental health needs.


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


It is important to remember that therapy takes commitment, hard work, and time. It is best not to judge your therapy by the way you are feeling in the moment. Therapy is not miraculous phenomenon. It is a collaborative effort between the counselor and an active and motivated participant. Counseling may open up levels of awareness that could cause pain and anxiety. Therefore, it is your right to refuse to participate in certain therapeutic techniques and you may terminate therapy whenever you decide. For therapy to be most effective, you will need to attend therapy sessions on time and on a consistent basis, and it is best to discuss termination with your counselor in a final session before you decide to end therapy.


As a client, you have the right to request referrals for other therapy services and psychopharmacology when necessary, request a copy of your records, participate in setting goals and evaluating progress toward meeting them, receive a copy of the code of ethics to which your counselor adheres, and contact the appropriate professional organization if you have doubts or complaints relative to this counselor’s conduct. Occasionally, I confer with other professional counselors about my work as a counselor. In these instances, I do not reveal the identity of my clients and in no way is your confidentiality compromised.


My work includes individual, couples, family, and group therapy. Individual sessions are 45 minutes in duration, couple and family sessions are 60 minutes in duration, and group sessions are 90 minutes in duration. The initial session is 70 minutes in duration at a fee of $200. My fee is $150 per individual session. Couple and family sessions are $180 per session. My fee for each person participating in group therapy is $40. I realize that not everyone can afford these fees per session. In an attempt to make counseling accessible to most people, I offer discounts or a sliding scale payment system. We can discuss this at your initial session. Payment is expected at the time of service. You may pay by check or cash. 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 to give you your full time. Regardless you will be charged for the full session. If you miss an appointment, that is time that could be spent with another client, therefore it is necessary for me to charge the regular $65 fee for missed appointments. There will be no charge if notice is given 24-hours before the scheduled session, if you have a documented illness, death of immediate family member, or other documented emergencies. After a missed appointment, if you do not reschedule within 14 days, I will accept that as your notice that you have terminated counseling. If check is found to have insufficient funds, a $42 charge will be added to fee and total must be paid in full prior to next session.

In case of mental health emergency during business hours, call 301 – 439 - 7191 ext. 4# to discuss the emergency. For all life-threatening emergencies, please call 911 first, then you may proceed to contact me


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 understanding and compliance with all statements above and obligates both client and clinician to abide by all rules and regulations as governed by the Maryland State Department of Health.

Who is signing?*
MM slash DD slash YYYY
I acknowledge that I am 18 years old or have legal authority to sign for the Client*
This field is for validation purposes and should be left unchanged.