Please fill out this form as best you can.
Consent for Social Work Services
I, Nicky Klima, am a Master of Social Work (MSW) intern enrolled in LSU's social work program. As part of my educational requirements, I will be providing social work services under the supervision of Yaffa Tilles at Boston Birth Village.
Please read, complete and submit to indicate your understanding and consent.
Nature and Purpose: I will offer support, guidance, and resources for social and emotional concerns.
Confidentiality: Your privacy is respected, but there are exceptions as mandated by law.
Risks and Benefits: Therapy can help, but may also bring up difficult emotions.
Alternatives: You have the right to explore other forms of support and can stop sessions at any time.
Fees and Payment: Counseling sessions are offered free of charge as part of my internship at Boston Birth Village. To honor the time set aside for you and to ensure others have access to these appointments, a $25 fee will be charged for sessions missed, canceled or rescheduled with less than 24 hours’ notice.
Rights and Responsibilities: You have the right to participate in your treatment and are responsible for attending appointments.
