• Informed Consent

    • Training, Credentials, and Effects. It is my understanding that my counselor, Tom Gozinske, a Wisconsin Licensed Professional Counselor in Training, will be providing me, and/or my dependent, counseling services. Counseling provided by Tom Gozinske may be beneficial, detrimental, or have no effect; there can be no guarantee that the person receiving the counseling will receive any benefit.
    • Nature of Services. In general, counseling services will be provided on a pre-scheduled basis. Counseling services provided may be overtly Christian, and may include Scriptural references and prayer, if I agree to this. Counseling may occur face-to-face, or may be done via electronic means, either synchronous or asynchronous. Emergency behavioral health services outside of the normal treatment session may be obtained by calling:
      • 911
      • 800-273-8255 (The National Suicide Prevention Lifeline)
      • 888-552-6642 (Richland County Health and Human Services)
      • 800-362-5717 (Grant and Iowa Counties Unified Community Services)
      • 741741 and text START (Crisis Text Line)
    • Confidentiality. Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification. The content of the counseling session and information pertaining to the client will remain confidential, with the following exceptions:
      • When the client threatens, or reports, serious and foreseeable harm to self or others;
      • During supervision or consultation with another counselor;
      • Under court order or another legal requirement;
      • Release to third-party payers when the client has authorized this;
      • As necessary for the transcription of records;
      • When the client releases the information;
      • When the guardian of a minor client requests.
    • Supervision. I understand that my counselor is operating under the supervision of another Professional Counselor. I understand that the content of my counseling sessions and/or video may be discussed with this supervisor only for the purposes of supervision and ongoing training in counseling skills.
    • Review of, and Challenge to, Records. The client has the right to review his or her records upon request. The client has the right to challenge information contained in the record by adding a statement into it.
    • Recording. The counselor may record all or part of my counseling sessions. I understand that the purpose of the recordings is solely to improve the quality of counseling that I am being provided. These recordings will be used only for the purposes of professional training, consultation and/or improving service in individual supervision (between counselor and supervisor) and/or group supervision (between the counselor, the supervisor, and other counselors). Put another way, these digital recordings are used for the training and the development of the counseling skills of the counselor. Recordings are erased after the supervision takes place, unless the recordings are needed for ongoing training.
    • Payment. I will personally be responsible for the payment of all related fees (including fees for missed appointments, or other similar situations). Fees will be imposed for all contacts with Tom Gozinske, and are payable upon delivery of services. Payment for missed appointments will be assessed at the sole discretion of Tom Gozinske.
    • Succession. In the event of Tom Gozinske’s incapacitation or demise, his wife Laura Jean Gozinske has agreed to serve as his Professional Executor. She will act on his behalf in making decisions about storing, releasing, and/or disposing of his professional records, consistent with relevant laws, regulations, and other professional requirements. She will have the authority to delegate and authorize other persons to assist her in this process.
    • Consent. I understand, and agree with, the information contained in this document, and am competent and able to make a rational decision about participating in the counseling services offered by Tom Gozinske. Or, I am the legally authorized person to allow the individual to participate in said counseling. I have the right to withdraw consent for treatment at any time.

    Professional Counselor. I understand that the content of my counseling sessions and/or video may be discussed with his supervisor only for the purposes of supervision and ongoing training in counseling skills.

    Client/Legal Guardian Signature Date
    Printed Name
    Tom Gozinske, MA, LPC-IT Date