Steven Eastmond, LCSW
1787 N. 750 E. Lehi, UT 84043 (801) 369-0053
------
Statement of Understanding for Couple Therapy
Account #: ______Today’s Date: 12/31/2018
Client Information
Client Name: ______DOB: ___/___/_____ Age: _____ M / F
Client Name: ______DOB: ___/___/_____ Age: _____ M / F
Address: ______City: ______Zip: ______
Phone (H): ______(W): ______(CHis):______(CHers): ______
Statement of Understanding for Couple Therapy
Couple therapy starts with an assessment of the relationship past and present.
We understand that information discussed in couple’s therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the partners.
We agree not to subpoena the therapist to testify for or against either party or to provide records in a court action.
By entering into couple’s therapy, we both understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach our goals. We accept that such changes can have both negative and positive effects and agree to clarify and evaluate potential effects of changes before we undertake them.
There will be times when the therapist may appear on either person’s side but is really on the side of the marriage.
Phone calls between sessions should be used for making appointments and emergencies only. Emails, texts, or printed documents should also be used only for those purposes unless directed by the therapist.
If the relationship breaks up and either or both of you wish to re-contract with me for individual counseling, the decision with whom I continue working is at my discretion. In some circumstances a referral will be made.
Since session time is limited to 50 minutes, try to be concise in presenting your thoughts and feelings.
Specific examples of what is happening are helpful to a point, beyond which they begin to detract from the therapeutic process and simply take up time. The therapist only need understand the patterns that exist in your relationship in order to help.
If the therapist sees either member of the couple for individual sessions as part of couple treatment, secrets will not be kept and the therapist reserves the right to pass on information that furthers therapeutic goals. That includes information divulged through email, telephone, or other forms of communication.
Free expression of feelings and thoughts is an important component of the therapeutic process. Choosing to say things that are cutting and degrading of one’s partner, however, can limit how safe the partner feels in expressing his or her feelings and should be avoided at all times. Expressing one’s feelings can be effectively done without using such terminology.
We agree to the above guidelines.
Signature: ______Date: ______
Signature: ______Date: ______
1
Statement of Understanding for Couple Therapy