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Housekeeping Checklist to Begin Service

If you have any questions regarding this information, please call 870-688-2040 or email at for immediate assistance.

Serving Idaho, Missouri and Arkansas

Before Services Can Begin, This Must be Read, Understood and Approved by You First.....

Important Information Needed for Your Review regarding client's rights, e-counseling, Emergency/Safety, Consent for Service, Waivers

1. Client's Rights: Person to Person Session.

To participate in developing an individual plan of treatment.

To receive an explanation of services in accordance with the treatment plan.

To participate voluntarily in and to consent to treatment.

To object to, or terminate, treatment.

To have records protected by confidentiality and not be revealed to anyone without my written authorization.

Confidentiality may only be broken under the following conditions (state laws will vary):

If the therapist has knowledge of child or elder abuse.

If the therapist has knowledge of the client's intent to harm oneself or others.

If the therapist receives a court order to the contrary.

If the client enters into litigation against the therapist.

To have access to one's records.

To receive clinically appropriate care and treatment that is suited to their needs and skillfully, safely, and humanely administered with full respect for their dignity and personal integrity.

To be treated in a manner which is ehtical and free from abuse, discrimination, mistreatment, and/or exploitation.

To be treated by staff who are sensitive to one's cultural background.

To be afforded privacy.

To be free to report grievances regarding services or staff to a supervisor.

To be informed of expected results of all therapies prescribed, including their possible adverse effects (eg.- medications).

To request a change in therapist.

To request that another clinician review the individual treatment plan for a second opinion

2.Client's Rights for Electronic Counseling:

Electronic counseling, legally, is placed into a different category compared to person to person contact. The difference is there can be no diagnosis provided by the therapist and no therapeutic techniques. These two services are ONLY legally available from a professional mental health therapist in the State you reside. If you are seeking a diagnosis, medication, psychiatric assessment and therapeutic techniques, please refer to your available mental health services provided in your area.

Electronic counseling is very effective and supportive for many issues; however, for chronic mental health issues, this service is not appropriate. Electronic counseling is not a substitute for mental health services needed for emergency care. 

3. Safety Comes First!

If you are having suicidal/homicidal ideations you need to make immediate contact with your local hospital or contact your local police for immediate attention.


CALL 911


Poison Control: 1-800-222-1222 FREE

Child Abuse Hotline: 1-800-422-4453 FREE

Sexual Assault Hotline: 1-800-656-4673 FREE

Domestic Abuse Hotline: 1-800-799-7233 FREE

Suicide Prevention Hotline: 1-800-273-8255 FREE

Runaway Switchboard (teen runaways): 1-800-786-2929 FREE

Boys Town Hotline (teen suicide/abuse): 1-800-448-3000 FREE

Center for Missing and Exploited Children: 1-800-843-5678 FREE


Family Members (parents, siblings, uncles/aunts, etc)

Friends (social, classmates, co-workers, etc)

Faith-based associates (pastor, preacher, reverend, chaplain, etc)

E-Counseling Network pro non-medical/non-emergency counseling services and it is not:

*an emergency or crisis line (for suicidal ideations, etc)

*a provider of medication or medical assessments

*associated with Emergency Services (such as hospitals), local authorities (such as the sheriffs department), or legal services (such an attorney's office)

4. Consent For Service Form

Welcome to L.I.F.E. Counseling Services. You are about to have a confidential counseling session and would appreciate you review of this form so you know what to expect during your counseling session. Services include: assessment and identification of personal issues; counseling; possible crisis intervention; follow up appointments when necessary; referral to appropriate community resources when needed.

All sessions are confidential; except for the following: If during your session, self -harm or harm to others is assessed, action for protection is necessary and immediate. If for any reason you have engaged in acts of child or dependent adult abuse or neglect, or that you were the victim of child abuse or neglect, there is an obligation to report that information to the appropriate government authorities.

There are certain circumstances in which office records concerning you can be required by court order to be disclosed; such as in a lawsuit in which your mental health is an issue.

I have read and understand the information outlined above. I understand that I will have an opportunity to discuss any questions I may have regarding L.I.F.E. Counseling services during my session. On the basis of the stated information, I consent to receive services with L.I.F.E. Counseling.


Waiver 1: All references to L.I.F.E. Counseling in this list of waivers shall include the website and its directors, shareholders, employees, officers, agents, affiliates, and attorneys, as applicable.

Waiver 2: All states require mental health professionals, including social workers, counselors, therapists, and psychologists to be licensed in the state(s) where they practice or receive their supervision by a licensed professional of the same state. At present time, there is no agreement regarding standards for interstate counseling. I therefore acknowledge that by choosing to enter into a session with anyone from LIFE Counseling that is outside of my state of residence, there is no guarantee that I am receiving professional counseling as defined by the governing bodies and professional standards set within my own state of residency. Furthermore, by choosing to enter into a session with anyone from LIFE Counseling that is outside of my state of residency, I have chosen to receive social conversation (which is NOT a form of therapy) from said individual(s) via electronic communication instead of traveling to the state for which he or she is legally licensed to practice or legally licensed to receive supervision to practice.

Waiver 3: As the client, I am responsible for implementing reasonable security measures to protect any and all information belonging to me and stored on my computer, laptop, or any other electronic device I use in communicating with eCounseling Network. I understand that LIFE Counseling is not responsible for any of the information or data I have stored that was provided or received before, during, and after all scheduled therapy sessions.

Waiver 4: LIFE Counseling does not guarantee or warrant that is free of viruses or other code containing destructive properties. As the client, I am responsible for implementing reasonable measures to prevent the loss of information, date, or code obtained through all my interactions with eCounseling Network.

Waiver 5: I acknowledge LIFE Counseilng is not responsible for delays or failure in performance resulting from acts beyond the control of LIFE Counseling such acts shall include but are not limited to acts of war, communication line failures, power failures, earthquakes, fire, or other disasters.


Email Address*

Are you 18 or older?*

Are you suicidal?*

I have read my Patient Rights & Waivers. I understood the contents.

I have read Safety Comes first and understand the contents.

I have read the consent for services and understand it's contents.


Email Address*


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