Online Counseling | Online Therapy | Complete Counseling Solutions

Online Therapy Consent Form

Please review and fill out our Online Counseling Client Consent Form

Instructions: Please review the Agreement & Consent Form below and answer as many of the optional questions as you are comfortable responding to. After you are done, please click the print button.
Once printed, please either fax or mail this form to:

Dr. Jennifer Lagrotte, DMFT
7856 NW 121st Way
Parkland, FL 33076
FAX: 954-255-3446

Welcome to Complete Counseling Solutions. This Agreement and Consent Form for online counseling is being provided to you (client) in order to inform you about Online Therapy and answer some questions you may have.

As a client of Complete Counseling Solutions, I understand that Online Therapy is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither the online counselor at Complete Counseling Solutions nor me. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction) or natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth). These types of problems are beyond the control of Complete Counseling Solutions and me (client). If something like this were to occur, any scheduled appointments would be re-scheduled by your online therapist at no additional cost to you (client).

I understand that I must be at least 18 years of age to consent for online counseling by Complete Counseling Solutions. (If not at least 18 years old, a parent or legal guardian must contact Complete Counseling Solutions and provide a written consent for services). As a client of Complete Counseling Solutions, I declare that I am free of suicidal thoughts. I also understand that Complete Counseling Solutions may be required to violate confidentiality to make appropriate legal notifications if your online therapist reasonably believes I am involved in child abuse or neglect, if I intend to harm myself, or if I am involved in criminal activity. If you desire more information, this is discussed in more detail in the Confidentiality section of the website.

I realize that I will be charged per a pre-arranged price that Complete Counseling Solutions and yourself agree upon. We need to recognize that during the process of online counseling psychotherapy, discomfort may arise (as difficult issues are addressed and worked through). This is an oftentimes necessary part of online therapy, even though it does not guarantee resolution of any kind or assure success for online counseling, either explicit or implied. This means that there is no guarantee as to the outcome from the services of or Complete Counseling Solutions. This includes limitation or restriction, of any guarantee, for information, online counseling, uninterrupted access, and other services provided through or Complete Counseling Solutions. In addition, as a client of Complete Counseling Solutions, I can end services at any time, for any reason, without prior notification or explanation to Complete Counseling Solutions. (Although a note explaining any decision to stop services would be greatly appreciated).

Lastly, although Complete Counseling Solutions has taken a significant number of steps to ensure the confidentiality and privacy of Online communication(s) between you and your online counselor, these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify Complete Counseling Solutions from all suits, claims, and other actions originating from psychotherapy provided through Complete Counseling Solutions.

Your Name:

By checking the box below, you agree to Complete Counseling Solutions' consent form.


Consent Questionnaire

The following information is being collected for professional purposes only. We strongly encourage you to fill out this questionaire in it's entirety in order to better serve you. Confidentiality of all submitted information will be strictly maintained.

Please answer as many questions as you can as thoroughly as possible.

Male Female
Email Address*:
Primary Telephone Number*:
Alternate Telephone Number:
Marital Status:
* Are you human?:
Sorry, we've been getting spammed so badly lately that we feel we need to ask you if you are in fact a human! :)
No, I am a spamming program
Yes, I am a real person No, I am a spamming program
Employment Status*:
Education Level:

Emergency Contact Info
Your Relation to this person*:
Their Phone Number*:
Their Address*:

Please briefly describe the problem(s) that you would like to discuss or work through:

How severe would you rate your symptoms?
Mild Moderate Severe

Are you currently getting treatment from a mental health professional?
Yes No
If yes, please explain:

In the past, have you been treated by a mental health professional?
Yes No
If yes, for what and what was the outcome:

Are you currently taking any psychotropic medication(s)? (e.g. anti-depressants or anti-anxiety medication)?
Yes No
If yes, please list them:

Have you taken any psychotropic medication(s) in the past?
Yes No
If yes, please list them:

How would rate the frequency of your alcohol intake?

What type of nicotine products do you use?

Do you use "recreational drugs"?
Yes No
If yes, please list them:

How would you rate your overall health?

Do you have any medical problems that you think contribute to your present situation?
Yes No
If yes, please briefly describe:

Tell us a little bit about what's going on:

Last Revised: 20090404

i To find out more or make an appointment for
online therapy, call toll free 866-900-0316.

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